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(Chest. 2003;124:1774-1780.)
© 2003 American College of Chest Physicians

Trends in Emergency Department Asthma Care in Metropolitan Chicago*

Results From the Chicago Asthma Surveillance Initiative

Richard Lenhardt, MD, MPH; Anita Malone, MPH; Evalyn N. Grant, MD and Kevin B. Weiss, MD, MPH

* From the Division of Emergency Medicine (Dr. Lenhardt), Center for Health Care Studies (Ms. Malone and Dr. Weiss), Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; Hines VA (Dr. Weiss), Hines; and Rush Medical College (Dr. Grant), Chicago, IL.

Correspondence to: Richard Lenhardt, MD, MPH, Division of Pulmonary and Critical Care Medicine, Rush-Presbyterian-St. Luke’s Medical Center, 1653 W. Congress Parkway, Jelke 297, Chicago, IL 60612; e-mail: richard-lenhardt{at}rush.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: The purpose of this study was to assess trends in emergency department (ED) asthma care in a single large community and to address how these trends meet expectations of national guidelines for asthma care.

Design and setting: This study is based on a repeated cross-sectional, self-administered survey of ED directors (or designees) in the Chicago area.

Participants: Fifty-one EDs that responded to both the 1996–1997 and 2000 surveys comprise the database for this study.

Results: Areas of significant improvement from 1996–1997 to 2000 include reduction in the use of theophylline (10.1% vs 3.1%, p < 0.0001), increased use of systemic steroid prescriptions at discharge (57.7% vs 77.2%, p < 0.0001), decreased use of arterial blood gas (ABG) analyses as part of the initial patient assessment (10.2% vs 4.5%, p = 0.02) and to document improvement after treatments (18.8% vs 8.9%, p = 0.03) and increased use of pulse oximetry as part of the initial patient assessment (95.1% vs 98.1%, p = 0.05). Areas of significant worsening of asthma care from 1996–1997 to 2000 include reduction in the use of ABG analyses in the assessment of severe cases (71.5% vs 47.5%, p < 0.0001), decreased use of instructions to inform patients what to do in the event of inability to attend their follow-up appointment (94.4% vs 38.9%, p = 0.0004), and decreased use of peak expiratory flow rate measurements to document improvement after treatments (82.7% vs 78.6%, p = 0.04).

Conclusions: From 1996–1997 to 2000, ED asthma care in metropolitan Chicago has improved in some areas and worsened in others. However, most aspects of asthma care have continued to fall short of national asthma guidelines. The lack of overall improvement with the current widespread knowledge of national guidelines suggests that a dissemination strategy of medical education by itself is not sufficient to improve ED asthma care.

Key Words: asthma • emergency • guideline adherence • practice guidelines • questionnaires


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Asthma is a common emergency department (ED) diagnosis. In 1995, EDs managed 1.9 million asthma-related visits in the United States.1 EDs are also an increasingly important source of asthma care. From 1992 to 1999, the yearly rate of asthma visits to EDs increased from 5.8 to 7.4 patients per 1,000 population.2 Asthma care in EDs in the United States has been influenced by important national trends and events in the 1990s: (1) the increase in utilization and overcrowding of EDs,3 4 5 (2) the greater prevalence of asthma in the United States,1 6 and (3) the publication of national guidelines regarding the management of asthma.7 8

Given the importance of EDs in managing asthma patients, studies have evaluated the quality of care provided. The initial ED asthma quality of care studies were chart audits,9 10 11 12 13 14 which often found deficiencies in care as low use of physiologic measures for asthma severity. After the publication of the first National Asthma Education and Prevention Program (NAEPP) asthma care guidelines in 1991,7 studies15 16 17 18 19 20 21 22 of various designs have examined the adherence of ED asthma care to national guidelines, and have found that ED asthma care often fails to meet national practice guidelines.

In 1996–1997, the Chicago Asthma Surveillance Initiative evaluated asthma practices of metropolitan Chicago EDs.18 This was the first large-metropolitan, community-based study of ED asthma care. The survey found that although many Chicago area EDs provided care consistent with national guidelines, the practices demonstrated a high degree of variability and often failed to meet guideline recommendations.18 This study is a follow-up survey to examine how these practices may be changing over time.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Study Design
This study is based on a repeated cross-sectional survey of EDs in the Chicago area.

Survey Instrument
The follow-up survey was composed of a 64-item, self-administered questionnaire. The questionnaire was the same (with minor modifications) as the questionnaire administered in the 1996–1997 survey.18 Respondents were queried on patient demographics, general ED characteristics, utilization statistics, assessment, treatment, prescription, educational and follow-up practices, and guideline beliefs and practices. Respondents in the 2000 survey were asked to refer to 1999 data for questions concerning utilization statistics, and were asked to provide actual numbers rather than estimates whenever possible.

Survey Population
EDs in the six-county Chicago metropolitan area (including Cook, DuPage, Kane, Lake, McHenry, and Will counties) were identified from the American Hospital Association 1999 guide.23 Eighty-nine hospitals with an American Hospital Association 1999 guide facility code of 22 (indicative of emergency medical services) were identified. Each ED was contacted by telephone to identify the medical director and to determine study eligibility. Eligible hospitals had to be nonmilitary and have an active ED in 1999. Eighty-eight hospitals met the eligibility criteria and were surveyed; 62 hospitals responded to the survey. Data presented in this report are restricted to the 51 hospitals that completed the survey in both 1996–1997 and 2000.

Data Collection
A survey package was mailed to the medical director of each of the 88 eligible EDs. The packet included a cover letter, the survey, and a postage-paid return envelope. To maximize the response rate, the nonrespondents of first mailing received additional mailings. The nonrespondents were contacted by telephone to ensure that the survey was received and the appropriate person from the ED had been identified. A nominal incentive was made available for completion of the survey.

Statistical Analyses
Tabular data are presented as means with SE, and medians with interquartile range (IQR). Data elsewhere are presented as means only. The mean and median for a given questionnaire item were calculated only for those EDs that responded in both survey years. Questionnaire items had a completion rate of >= 90% unless otherwise indicated. In Table 1 , the percentage rate of asthma visits to total ED visits was calculated by first dividing the annual number of asthma visits of each hospital by the annual ED census, and then calculating the summary statistic. Two items on the questionnaire pertaining to national guidelines had respondents indicate their beliefs on a 1 to 10 visual ordinal scale. Statistical testing was performed after dichotomizing responses into groups with values of 1 to 5 and 6 to 10.


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  		Table 1. Trends in Annual Utilization Characteristics of Chicago-Area EDs

 
Inferential testing for continuous variables was performed as a paired analysis using the Wilcoxon signed-rank test. For count data, the {chi}2 or Fisher exact test was used, where appropriate. Statistical testing was two sided, with a p = 0.05 denoting significance. Statistical computations were performed with statistical software (Version 8; SAS Institute; Cary, NC). This study was approved by the Northwestern University Feinberg School of Medicine Institutional Review Board.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
General ED Characteristics and Utilization Statistics
In the 1996–1997 survey, 64 of 89 EDs returned the surveys, for a response rate of 72%. In the 2000 survey, 62 of 88 EDs responded, yielding a response rate of 70%. Of the 62 responding EDs, 51 EDs also responded in the 1996–1997 survey. The group of 51 EDs that responded in both surveys is the focus of this report. In both surveys, 96.0% of respondents were administrative physicians, holding the title of either director (or chairperson) or associate/assistant director.

General ED characteristics were not significantly different between the two surveys. In the 1996–1997 and 2000 surveys, 92.0% and 94.0% of respondents, respectively, noted that their department was a general ED (treats both children and adult patients). Forty-four percent of respondents in the initial survey and 37% in the subsequent survey noted that their EDs supported an accredited ED training program; 20% and 18.0% of EDs, respectively, also supported a pediatric training program.

The respondents’ estimated ED utilization statistics are provided in Table 1 . Yearly ED visits for all conditions increased from 33,100 to 35,500 (p = 0.002), and yearly hospital admissions via the ED trended upwards from 6,200 to 7,000 (p = 0.06). Asthma-specific utilization statistics were unchanged between the two surveys. The estimated asthma relapse rates at 7 days after the ED visit were unchanged in the two survey periods.

Patient Characteristics
The estimated percentage of asthmatic patients who have a regular source of care decreased from 69.8% in the initial survey to 59.1% in the subsequent survey (p = 0.005). Estimated health insurance carriers (private, Medicare, Medicaid, or other) were unchanged except for an increased prevalence of Medicare (18.2% vs 22.5%, p = 0.04 and n = 41).

Asthma Assessment
As in the 1996–1997 survey, the 2000 survey questioned respondents about the use of four asthma assessment tools: peak expiratory flow rate (PEFR) measurements, pulse oximetry, arterial blood gas (ABG) analysis, and chest x-rays (CXRs) [Table 2 ]. The estimated use of PEFR measurements to document improvement after treatments declined from 82.7% to 78.6% (p = 0.04). The estimated use of PEFR measurements as part of the initial assessment nearly significantly declined from 78.0% to 71.4% (p = 0.08).


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  		Table 2. Trends in Prevalences of Asthma Assessment Practices Among Chicago-Area EDs

 
Pulse oximetry utilization was assessed in both surveys. The estimated use of pulse oximetry as part of the initial assessment increased from 95.1% to 98.1% (p = 0.05). Respondents reported decreased use of ABG analysis, regardless of its indication: as part of the initial assessment, to document improvement after treatments, and as an assessment of patients with severe asthma. Respondents reported comparable rates of ordering CXRs in both surveys, with the exception of a trend towards disease in the use of CXRs in patients with wheezing and fever (79.2% to 71.6%, p = 0.09).

Asthma Treatment
Table 3 presents the respondents’ replies on the duration of treatment involving the care of asthma patients and the use of various therapeutic interventions. The estimated treatment times were not significantly different in the 1996–1997 and 2000 surveys.


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  		Table 3. Trends in Prevalences of Asthma Treatment Practices Among Chicago-Area EDs

 
With one exception, both surveys demonstrated comparable estimated rates of use of various treatments. All respondents reported that a bronchodilator was the first medication patients received in the ED. According to both surveys, slightly more than a majority of patients received IV or oral steroids within the first hour of the ED visit. Nearly three fourths of patients were estimated to have received IV or oral steroids at any time during the ED stay, in both time periods. Supplemental oxygen was used in an estimated three fourths of patients, across both surveys. The only significant treatment change reported between the surveys was the use of theophylline, which declined from 10.1% to 3.1% (p < 0.0001).

Prescription, Educational, and Follow-up Practices
Overall, responses to prescribing behavior had not changed significantly, with the exception of prescriptions written for systemic steroids (Fig 1 ). In the 1996–1997 survey, an estimated 57.7% of patients received a prescription for systemic steroids at discharge. In the 2000 survey, this increased significantly to 77.2% (p < 0.0001). Prescriptions for inhaled steroids/cromolyn and antibiotics remained in the 15 to 25% range in both surveys. Respondents’ opinions that inhaled steroids (in the treatment of an exacerbation) are very important or somewhat important were not significantly different (59.2% in 1996–1997 and 73.5% in 2000, p = 0.13).



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  		Figure 1. Trends in frequency of prescription practices reported by Chicago-area EDs.

 
With one exception, discharge educational and follow-up practices were not significantly changed in the two surveys (Table 4 ). Respondents estimated that formal education (according to a protocol) was given to less than half of the patients in both surveys. Approximately half of all patients in both surveys were believed to have received written asthma educational material. On another educational material questionnaire item, respondents estimated that approximately half of the patients received a written asthma action plan in both surveys. Of those EDs using such a written plan, nearly all were reported to include information on what defines worsening of disease. The estimated use of a written asthma action plan that describes what the patient should do if they are unable to acquire follow-up appointments declined from 94.4% to 38.9% (p = 0.0004). Both surveys found that specific follow-up appointments were given to an estimated one fourth of patients. A majority of patients in both surveys were given peak flow meters or advised to obtain one at discharge (59.6% in 1996–1997 and 72.3% in 2000, p = 0.19).


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  		Table 4. Trends in Prevalences of Discharge Care Practices Among Chicago-Area EDs

 
Guidelines Beliefs and Practices
Respondent beliefs and practices regarding asthma care guidelines are presented in Table 5 . Nearly all respondents in both surveys had heard of the national guidelines for asthma assessment and treatment (the first or second NAEPP expert panel report). A large majority of respondents affirmed having read the report(s) in both surveys. Based on a Likert scale, 90 to 95% of respondents in both surveys thought the guidelines were beneficial. An equally high proportion of respondents (90%) in both surveys replied that they follow the guidelines. Despite the widespread knowledge and use of the national guidelines, their implementation into ED practices was not formalized to the same extent. Only approximately half of respondents in both surveys noted that their ED uses a written protocol or guidelines in the treatment of asthma patients. Similarly, a majority of, but not all, respondents encouraged the use of asthma guidelines by the ED staff.


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  		Table 5. Trends in Guideline Beliefs and Practices in Asthma Care Among Chicago-Area EDs

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Since the publication of the first NAEPP guidelines,7 studies15 16 17 18 19 20 21 22 have demonstrated that asthma care practices frequently fail to meet national recommendations. To our knowledge, this is the first survey to report on the trend of ED practices. This study demonstrates that ED practices of asthma care in the Chicago area have become more consistent with national guidelines in some areas, but remain lacking in others. Areas of significant improvement from 1996–1997 to 2000 include a reduction in the use of ABG analyses as part of the initial patient assessment and to document improvement after treatments, increased use of pulse oximetry at initial assessment, reduction in the use of theophylline, and increased use of prescriptions of systemic steroids at discharge.

This study, while not designed to elucidate the reasons for the observed improvements, nevertheless permits the observation of such changes. The improvements may be the result of knowledge dissemination through educational forums including the following: (1) the publication of the expert panel reports of the NAEPP in 1991 and 1997, and a review of the second report published in a prominent emergency medicine journal in 1998; (2) the development of the Chicago Emergency Department Asthma Collaborative (a local collaborative quality improvement group); and (3) other national and local educational venues, as is typical of any specialty in medicine.7 8 24 25 Other factors that may influence ED physicians’ practice behavior, as incentives, were not measured in this study.26

Despite the improvements between the two survey periods, other areas persistently fell short of guidelines for asthma care. These areas outnumbered the improvements observed. In all aspects of asthma care—assessment, treatment, discharge and guideline practices—areas were found to be persistently below optimal care or (occasionally) to have significantly worsened between 1996–1997 and 2000. Areas of significant worsening of asthma care include decreased use PEFR measurements to document improvement after treatments, decreased use of ABG analysis in assessing severe asthma, and decreased use of instructions informing patients what to do if they are unable to obtain a follow-up appointment.

The reasons for the lack of more widespread ED asthma care improvements are not clear. Factors that may impact on the underperformance include ED overcrowding seen in the United States and physician time fragmentation that is part of the daily practice of emergency medicine.3 4 5 27 Results from this study support overcrowding as a factor, in that respondents’ estimated an increase in total ED visits between the surveys and areas of improvement between the surveys tended to be less physician time dependent. For example, prescription writing of steroids at discharge (improvement) occupies a shorter period of physician time than patient education (no improvement).

The lack of widespread improvements in asthma care practices of EDs between the two time periods suggests that interventions other than the publication and dissemination of guidelines are necessary to achieve improvements.28 29 One such intervention is the use of ED asthma care pathways, which improve assessment and treatment practices and reduce costs.30 31 32 33 34 Despite this, only half of EDs in this study used written protocols or guidelines. Educating housestaff physicians also improves asthma care practices.35 Even the presence of an ongoing asthma care audit seems to improve adherence to practice guidelines.36 These studies, along with the current study, imply that systems are not optimally established to maximize ED asthma care.

As with all studies, limitations to this study should be noted. First, we recognize that physicians’ self-report of ED care may not attain the accuracy of directly observed care. Despite this limitation, a strength of this study was its consistent design that enabled trends to be followed. Second, although an acceptable 70% of eligible hospitals responded to the surveys, the results may not be generalizable to all hospitals. Third, it could be that more time is necessary before significant widespread changes in clinical practices occur. Given the involvement of the Chicago area medical community in the Chicago Asthma Consortium and the regional EDs in the Chicago Emergency Department Asthma Collaborative, it is plausible that changes would occur in the 3 to 4 years between the two surveys.25 37 Finally, this study examined EDs only in the Chicago area, and the findings may not be generalizable to other regions. This is unlikely given the diverse economic and ethnic makeup of the region.

In the current study, using the respondents’ estimates, the average annual number of hospitalizations through the EDs for asthma, per 10,000 population, was 31.9. This is greater than the national average of 17.6 and less than 42.0 and 39.2, respectively, derived in prior studies38 39 40 for the cities of Boston and New York. Differences in these rates may be related to the various ways in which the sources obtained the data.38 39 40

In summary, this study demonstrates that in Chicago area EDs, adherence of asthma care to national guidelines continues to fall short in many areas in 2000 as it did in 1996–1997. Optimism related to areas of improved asthma care is mitigated by finding areas of worsened care and the lack of an overall improvement between the two periods. The passage of several years alone in the presence of national asthma guidelines is not sufficient to enhance asthma practices in EDs. Further studies, based in a community of EDs, should investigate various interventions that could improve asthma care in those EDs.


   Acknowledgements
 
The authors thank Michael McDermott, MD, and Cathy Catrambone, DSc, for assisting in survey development; Monica Hagarty for assistance in data collection; Chris Lyttle for statistical support; and the ED chairpersons (and their designees) of the participating Chicago metropolitan EDs.


   Footnotes
 
Abbreviations: ABG = arterial blood gas; ED = emergency department; CXR = chest x-ray; IQR = interquartile range; NAEPP = National Asthma Education and Prevention Program; PEFR = peak expiratory flow rate

Supported by a grant from the Otho S.A. Sprague Memorial Institute.

Received for publication November 8, 2002. Accepted for publication June 18, 2003.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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