Guideline-based acute paediatric asthma care infrequent in US emergency departments

An analysis of over 7 million ED visits for acute asthma in children has revealed how only 34% of visits were guideline adherent although this increased to 42% in paediatric ED centres.

According to the World Health Organization, asthma affected around 262 million people in 2019, leading to an estimated 461,000 deaths and is the most common chronic disease among children.1 Moreover, one US study found that visits to the emergency department (ED) for asthma in children increased by 13.3% between 2001 and 2010.² Guidance on the treatment of acute asthma within the ED has discouraged the routine use of chest X-rays and antibiotics while encouraging the use of systemic corticosteroids.³ Though some studies have examined the level of agreement with these individual recommendations, finding, for example, that the use of chest X-rays and antibiotics were less likely,⁴ no studies have examined these three quality markers, i.e., no chest X-ray, no antibiotics given and provision of systemic corticosteroids, simultaneously. Consequently, a team from the Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, US, set out to examine the rates of adherence to these three indices during ED visits for children with asthma.⁵ For comparative purposes, the team also compared alignment with these measures in both general and paediatric ED centres. 

The team used a cross-sectional design and captured data from the National Hospital Ambulatory Medical Care Survey, which is a nationally representative survey of hospital ED visits, and which is conducted annually. The researchers focused on all ED visits for patients aged between 2 and 18 years of age from 2005 to 2013 with a diagnosis of asthma and documentation of bronchodilator administration at the ED. They used a composite outcome measure based on the three criteria of administration of a systemic corticosteroid either in the ED or via a prescription, no use or prescription of an antibiotic and no chest X-ray being used.

Findings

The dataset included 7,794,163 eligible ED visits with 877,342 made to a paediatric ED. Overall, 44% of visits were for children aged 2–6 years (59% male). The majority of children were of White (54%) or Black (41%) ethnicity with the remainder being Hispanic or Latino (27%) or other (5%). When comparing general and paediatric ED visits, there was no difference in the rates of corticosteroid use (63% vs 62%, paediatric vs general, p = 0.80) although rates of antibiotic prescribing were significantly lower at paediatric centres (11% vs 20%, paediatric vs general, p = 0.01). In contrast, use of chest X-rays was significantly higher in general EDs (26% vs 40%, paediatric vs general, p = 0.002). Overall, guideline-based acute asthma paediatric care was significantly more likely at a paediatric ED centre (42% vs 31%, paediatric vs general, p = 0.004). Interestingly, multivariate analysis revealed how only paediatric ED type, Black ethnicity and hospitals located in the western part of the country were independently associated with guideline-compliant care.

The authors concluded that guideline-based ED care for acute exacerbations of asthma occurred relatively infrequently in US EDs but was more common, although still less than optimal, within paediatric ED centres. They called for future studies to examine the factors associated with optimal, guideline-based care.

References

1. Asthma. World Health Organisation. www.who.int/news-room/fact-sheets/detail/asthma 
2. Nath JB et al. Children’s emergency department use for asthma, 2001–2010. Acad Pediatr 2015;15(2):225–30.
3. Camargo CA et al. Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. J Allergy Clin Immunol 2009;124:S5–S14. 
4. Chamberlain JM et al. Practice Pattern Variation in the Care of Children with Acute Asthma. Acad Emerg Med 2016;23(2):166–70.
5. Hudgins JD et al. Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments. Pediatr Emerg Care 2021;37:507–12.