Results Summary
What was the research about?
Asthma affects 1 in 10 children in the United States. When asthma isn’t managed well, children may need treatment in an emergency room, or ER. Doctors in the ER can use guidelines based on research to decide how to prepare families to manage asthma after they go home.
This study compared three ways to prepare children and caregivers to manage asthma after they leave the ER:
- Guideline-based, ER only. In this approach, the children and caregivers received instructions in the ER about how to use their medicines and inhalers. Afterward, ER staff set up follow-up office visits.
- Guideline-based, ER plus home visits. In addition to the meeting in the ER, children received up to five at-home visits from a community health worker who reviewed information and instructions from the ER meeting.
- Enhanced usual care. Children received the care usually provided in the ER, plus education on how to use their inhalers. Children also received two free inhaler spacers. A spacer is a tube that holds the medicine in place so that it’s easier to breathe in.
What were the results?
The three ways of preparing families to manage asthma at home didn’t make a difference in how families said asthma affected their lives, such as whether children had trouble breathing or if caregivers could work. However, compared with children who received enhanced usual care, children who received guideline-based care in the ER—with or without home visits—were more likely to
- Use medicine at home, including steroids, inhaler medicine, and rescue medicine
- Schedule an office visit
Children who received at-home visits were more likely to fill prescriptions and go to the office visit than children who received guideline-based care in the ER only or enhanced usual care.
Who was in the study?
The study included 373 children ages 5 to 11 who received care at six hospitals in Chicago. Of these children, 64 percent were black, and 31 percent were Hispanic or Latino. The average age was 7, and 67 percent were boys. Eighty percent had public insurance.
What did the research team do?
The research team assigned children, by chance, to receive one of three types of care. During the ER visit and six months later, the team asked children and caregivers to fill out a survey about how asthma affected their lives. The team also looked at patients’ health and pharmacy records to find out how often
- Children got an appointment for an office visit
- Children went to the office visit
- Children got prescriptions for asthma medicine before leaving the ER
- Caregivers filled children’s prescriptions
Doctors, community health workers, public health officials, people with asthma, and caregivers of children with asthma helped plan the study.
What were the limits of the study?
The research team enrolled fewer children in the study than planned. In addition, only 63 percent of children completed the six-month study. Results may have been different if more children had enrolled in or completed the study.
Future research could look at how guideline-based meetings and the use of community health workers affect children and caregiver’s lives with more people in different locations.
How can people use the results?
Hospital staff and doctors can consider the results when planning ways to help children and caregivers manage asthma at home after going to the ER.
How this project fits under PCORI’s Research Priorities PCORI identified asthma in African American and Hispanic/Latino populations as an important research topic. Patients, clinicians, and others wanted to learn how to encourage care that follows national asthma guidelines and improves patient-centered outcomes for African American and Hispanic/Latino populations. In 2013, PCORI launched an initiative on Treatment Options for African Americans and Hispanics/Latinos with Uncontrolled Asthma. The initiative funded this research project and others. |
Professional Abstract
Objective
To compare three discharge approaches for preparing children with uncontrolled asthma treated in the emergency department (ED) and their caregivers to manage asthma
Study Design
Design Elements | Description |
---|---|
Design | Randomized controlled trial |
Population | 373 children ages 5–11 who present to the ED with uncontrolled asthma |
Interventions/ Comparators |
|
Outcomes |
Primary: effect of asthma on child, effect of asthma on caregiver Secondary: guideline-based discharge instructions, prescription for inhaled corticosteroids or other controller medication, prescription for quick-relief medication, prescriptions filled, follow-up appointment scheduled, follow-up appointment attended |
Timeframe | 6-month follow-up for primary outcomes |
This multicenter trial compared three discharge approaches for children who present with uncontrolled asthma in the ED:
- Guideline-based, ED-only discharge instructions. Clinicians provided structured, guideline-based discharge instructions to children and caregivers in the ED. Children and caregivers received training on appropriate use of quick-relief medication and daily and systemic corticosteroids, how to avoid asthma triggers, and recognizing symptoms that require medical attention. Staff also scheduled a follow-up appointment for the children.
- Guideline-based ED discharge instructions plus home visits. In addition to the guideline-based discharge instructions provided in the ED, children received up to five at-home visits over six months from a community health worker to help implement discharge instructions.
- Enhanced usual care. Children and caregivers received usual ED care plus two free inhaler spacers and education about inhaler techniques.
Participants in the study received care at six clinical centers in Chicago. The research team randomized 373 children ages 5–11 to one of the three interventions. Of the children, 64% were black, and 31% were Hispanic or Latino. The children’s average age was 7, 67% were male, and 80% had public insurance.
During the initial ED visit and six months later, the research team surveyed children and caregivers about the effect of asthma on their lives, such as whether children had trouble breathing or if caregivers could work. The team also reviewed patient records and pharmacy data.
Clinicians, community health workers, public health officials, individuals with asthma, and caregivers of children with asthma helped plan the interventions and select outcomes.
Results
Asthma’s effect on the lives of children or caregivers did not differ across the three groups. However, compared with children receiving enhanced usual care, children in the two groups who received the guidelines-based ED discharge instructions were more likely to
- Use systemic corticosteroids at home (p<0.0001 for both groups)
- Use inhaled corticosteroids at home (p<0.001 for both groups)
- Use inhaled rescue medications at home (p<0.001 for both groups)
- Receive a follow-up appointment within four weeks of ED discharge (p<0.00001 for both groups)
Children in the ED plus home visits group were more likely to have prescriptions filled within seven days of ED discharge than the ED-only or enhanced usual care groups (p<0.001). Children in the ED plus home visits group were more likely to attend follow-up appointments than children in the enhanced usual care group (p=0.0005), but not the ED-only group.
Limitations
The research team was unable to enroll as many participants as planned, and only 63% of children remained in the study at six months, limiting the statistical power of the analyses.
Conclusions and Relevance
Providing guideline-based discharge instructions in the ED did not change the effect of asthma on children or caregivers’ lives compared with usual care. However, children who received guideline-based discharge instructions in the ED were more likely to fill prescriptions for asthma-controlling medications and to report using those medications at home.
Future Research Needs
Future research could further examine the impact of guideline-based discharge instructions and use of community health workers on children and caregivers’ lives, with a larger sample and in other geographic locations.
How this project fits under PCORI’s Research Priorities PCORI identified asthma in African American and Hispanic/Latino populations as an important research topic. Patients, clinicians, and others wanted to learn how to encourage care that follows national asthma guidelines and improves patient-centered outcomes for African American and Hispanic/Latino populations. In 2013, PCORI launched an initiative on Treatment Options for African Americans and Hispanics/Latinos with Uncontrolled Asthma. The initiative funded this research project and others. |
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Stories and Videos
Media Mentions
Chicago Hospitals Form Partnership to Battle Asthma 'Hot Spots'
Chicago Sun-Times, May 9, 2018
This article describes this PCORI-funded study, which found that families of children who visited the emergency room for asthma and who received extra help were better able to manage prescriptions and subsequent doctor visits than those who didn’t receive additional support. “We work as a team, around the clock,” one caregiver involved in the program tells the newspaper. “Once we learned the triggers for each child’s asthma, we have been able to manage it more effectively. You have to be proactive.”
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
In general, the reviews were positive regarding the study’s conduct. Reviewer criticisms focused on seeking greater clarity and explanation in the text. In particular, reviewers asked for more detail on the interventions and how the researchers sought to maximize retention of project participants. The researchers revised the report to include additional description and discussion.