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Randomized Controlled Trial of Emergency Department Interventions To Improve Primary Care Follow-up for Patients With Acute Asthma^*

^* From the Hospital of the University of Pennsylvania (Dr. Baren), Philadelphia, PA; Cooper Hospital Medical Center (Dr. Boudreaux), Camden, NJ; University of Arkansas (Dr. Brenner), Little Rock, AK; MetroHealth Medical Center (Dr. Cydulka), Cleveland, OH; University of Alberta (Dr. Rowe), Edmonton, AB, Canada; the Department of Emergency Medicine (Ms. Clark), Massachusetts General Hospital; Boston, MA; and Channing Laboratory (Dr. Camargo), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

Correspondence to: Jill M. Baren, MD, Department of Emergency Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, Ground Floor Silverstein Bldg, Philadelphia, PA 19104; e-mail: barenj{at}uphs.upenn.edu

Abstract

Objective: Emergency department (ED) visits for asthma are frequent and may indicate increased morbidity and poor primary care access. Our objective was to compare the effect of two interventions on primary care follow-up after ED treatment for asthma exacerbations.

Methods: We performed a randomized controlled trial of patients 2 to 54 years old who were judged safe for discharge receiving prednisone, and who were available for contact at 2 days and 30 days. Patients were excluded if they were previously enrolled or did not speak English. Patients received usual discharge care (group A); free prednisone, vouchers for transport to and from a primary care visit, and either a telephone reminder to schedule a visit (group B); or a prior scheduled appointment (group C). Follow-up with a primary care provider for asthma within 30 days was the main outcome. Secondary outcomes were recurrent ED visits, subsequent hospitalizations, quality of life, and use of inhaled corticosteroids 1 year later.

Results: Three hundred eighty-four patients were enrolled. Baseline demographics, chronic asthma severity, and access to care were similar across groups. Primary care follow-up was higher in group C (65%) vs group A (42%) or group B (48%) [p = 0.002]. Group C intervention remained significant (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.1) when adjusted for other factors influencing follow-up (prior primary care relationship, insurance status). There were no differences in ED, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year after the index ED visit.

Conclusion: An intervention including free medication, transportation vouchers, and appointment assistance significantly increased the likelihood that discharged asthma patients obtained primary care follow-up but did not impact long-term outcomes.

Key Words: asthma • emergency department • follow-up • primary care

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