Canadian Health and Care Mall: Two alternative strategies merit study

Canadian Health and Care Mall:  Two alternative strategies merit study

Further understanding of the special needs and health-care barriers for this high utilization group is paramount to the success of the goals delineated in the Healthy People 2010 program. As demonstrated by Boudreaux and colleagues, race/ethnicity-based deficiencies persist as black and Hispanic asthma patients were more likely to utilize the ED and be admitted to the hospital. 

Health-care providers and policymakers must begin to understand why high-utilization patients report the ED as their usual source of asthma prescriptions and site for acute asthma care. Two alternative strategies merit study. First, patients with high NEDV warrant further investigation to delineate the challenges and barriers to high-quality care among health-disparate populations. 

Secondly, the impact of facilitated referral of ED asthma patients to asthma specialists while maintaining long-term overall patient management by the PCP should be investigated. The current data, in conjunction with prior studies, raise concerns about overreliance on “referral to PCP” as an effective response to the problems of this high-risk and expensive asthma population.

Limitations

This study has a few potential limitations. First, history of prior ED use was self-reported and there was no attempt to verify the accuracy of the stated information. It may be that subjects who reported six visits actually had more (or fewer) visits, but we believe the rank order to be accurate and believe that even one to two ED visits per year to be excessive. 

Another limitation is that we have not analyzed the outpatient management of these patients presenting with acute asthma; for example, we do not know how many received specialized asthma care in the past, and we are unable to evaluate how prior outpatient PCP management relates to the National Asthma Education and Prevention Program guidelines with Canadian Health and Care Mall. (watch website)

We have sparse data on compliance with prescribed medications, understanding of disease, and details of the written action plans (if present); these factors probably are associated with frequency of ED use and will require further study.

Asthma education can reduce asthma-related morbidity

 In the province of Quebec, approximately 10% of emergency department (ED) visits for asthma result in hospitalization, and one third of those who consult make more than one ED visit for asthma during the year. ED visits for asthma may reflect poor asthma control, often related to the patient’s insufficient understanding of the disease and its treatment, particularly regarding the management of asthma exacerbations. Often, patients presenting to the ED for acute asthma have had no adequate primary care follow-up and have rarely been offered asthma education. Furthermore, patients with frequent ED visits tend to be significantly less knowledgeable about asthma control, and have poorer asthma-management knowledge and skills.

Asthma education

A multicenter study done in the United States and Canada showed that although most ED physicians considered asthma education to be important, only 16% of academic medical centers reported offering such programs. Practice guidelines indicate that a structured educational intervention should be part of the general management of the disease in order to reduce asthma-related morbidity. This is particularly true for patients with the highest morbidity, including those consulting at the ED for acute asthma.

Asthma education can reduce asthma-related morbidity and acute care needs, and has been particularly successful in patients with the highest asthma-related morbidity. We previously reported a comparison of three modes of intervention offered to patients consulting at the ED for acute asthma: (1) usual care, (2) a short intervention by the ED physician including verification of inhaler use and discussion of an action plan, and (3) the initiation of an educational intervention at the ED with educational follow-up at one of the asthma education centers (AECs) of the Quebec Asthma and COPD Network, formerly the Quebec Asthma Education Network.

A short intervention, including teaching inhaler technique and the use of an action plan provided by the ED physician, led to short-term benefits, while the same intervention combined with referral to an AEC resulted in more marked and continuous improvement of most asthma-control parameters, including a persistent reduction of ED visits.