Back for more: a qualitative study of emergency department reattendance for asthma

Episodes of severe asthma should be mostly preventable with current best treatment, yet asthma remains one of the most common reasons why patients seek emergency care, both from general practitioners and hospital emergency departments.1,2 Previous studies have shown that 62% of children and 40% of adults re-present for emergency department (ED) care within 1 year.3 These high ED reattendance rates suggest that this group of patients is at increased risk of poor asthma outcomes. The notion that ED attendance for asthma may be prevented by optimal asthma care has been supported by the Victorian Government’s description of asthma as an “ambulatory care sensitive condition”.4

A number of ideas have been proposed as to why some individuals recurrently seek emergency care for asthma. Primarily, these relate to the inability to obtain ongoing medical care because of personal, social or economic reasons. The American experience points to a lack of primary care as a reason for recurrent presentations, although the differences in social welfare and healthcare systems between the US and Australia make this less likely to be a reason in Australia.5 A less frequently discussed explanation is that patients who attend repeatedly may have more severe disease. 6,7

Effective interventions to prevent ED reattendance for asthma will depend on understanding why this occurs. Our qualitative study explores the reasons why patients present to ED on multiple occasions, and may help to identify possible modifiable factors

Our recruitment of patients has been described previously.8,9 For this study, we looked specifically at patients who reattended emergency departments within 12 months. Of an initial 195 ED attendees, 62 (32%) completed their participation in the study (Box 1). Briefly, data were collected from all consenting individuals who attended a city teaching hospital and a suburban hospital in the 2 months from 1 March to 30 April 2000, and a regional hospital between 1 July and 31 August 2000, for emergency asthma care.

Semistructured indepth interviews were conducted, exploring participants’ history of asthma and decision to present to the ED. Demographic data were collected, as well as responses to the European Community Respiratory Health Survey10 and Asthma Knowledge Questionnaire.11 Interviews were recorded and transcribed. Chronic asthma severity was determined from medical records according to the Australian Asthma Management Guidelines,12 and was thus predominantly based on medication use before emergency presentation. Acute severity was determined by peak expiratory flow measurements on presentation to the ED, in comparison with British Thoracic Society guidelines.13

Potential measures for preventing hospital presentations were identified in about a third of patients, predominantly those with chronic mild and moderate asthma. These measures are shown in Box 4. Among participants who presented with mild or moderate acute asthma, three had severe chronic asthma and had had previous life-threatening attacks. For these participants, presentation to the ED with mild or moderate asthma was indicative of careful attention to preventive asthma management plans. In this small group with likely brittle asthma, presentation to an ED is an important resource for managing the threat of precipitate attacks.

We invited consecutive ED attendees in a range of geographic locations to participate in our study during recruitment periods. Our recruitment rate was only 32%, despite strenuous attempts to contact individuals after presentation; this is probably partly a result of the transient nature of the population attending EDs. Our response rate raises legitimate questions about the generalisability of our findings, but does not invalidate our qualitative conclusions where thematic saturation was reached (ie, no new themes emerged), nor the comparisons drawn between non-reattenders and reattenders to the ED. To improve participation rates, future studies would need to be prospective, conducted at the time of ED attendance, probably by means of questionnaires.

Further limitations of our study include the fact that participants from the city and suburban hospitals were recruited during autumn, while those at the regional hospital were recruited in winter. However, this did not appear to reflect a difference in the triggers that led to ED presentations, as most were thought to be the result of RTIs. The link between RTIs and both asthma exacerbations16 and hospital admissions17 is well established. Nearly 60% of the ED reattendees stated that their presentation for emergency asthma care was brought about by a respiratory infection.

For many of these, a visit to their general practitioner had failed to prevent their asthma worsening, leading to the need for eventual hospital care. This is consistent with recent findings showing that deterioration in asthma in patients using inhaled medications for prevention was often sudden and prolonged.18 This suggests that inhaled preventive therapies may not sufficiently ameliorate airway responses to infections, and that more aggressive therapy with oral corticosteroids may be necessary to prevent severe exacerbation.

We know that 15 of the 32 reattendees in our study were taking prednisolone to manage their severe asthma. However, we did not ascertain whether all of these individuals had received high-dose prednisolone before presenting to the ED. Our findings suggest that doctors should consider the use of short courses of high-dose oral corticosteroids in patients with exacerbations of asthma attributed to infections, to prevent emergency presentations.

The inability of three reattendees to afford medication influenced their multiple presentations to the ED. Treatment costs for asthma include both medication and medical consultations. Costs are therefore high in patients with severe asthma. Previous work by our group9 has shown high treatment costs are further compounded by diminished employment opportunities for people with asthma, and resulting low socioeconomic status. These findings lead us to recommend consideration of specific financial assistance for asthma management in people with severe asthma to prevent emergency re-presentations.

Another modifiable reason for ED re-presentation was lack of asthma knowledge. Existing evidence shows that asthma education is beneficial when delivered in the context of regular medical review and a written asthma management plan.3 Current Australian data suggest that the ownership of written asthma action plans is declining, despite their being promoted to health professionals and the community in national asthma guidelines in the last decade.19,20,21 Clearly, new strategies are needed within primary care to ensure that asthma care meets current standards of best practice. One approach may be to promote greater access to asthma nurse educators. Currently in Australia, such access is not uniform, and methods of payment for this service are not generally subsidised by health insurance. Given the financial disadvantage already experienced by many people with asthma, additional cost subsidies are indicated if this mechanism is to be effective. Alternatively, the government-funded Asthma 3+ Visit Plan may provide GPs with an incentive to provide asthma education, written asthma management plans and regular review.22 The efficacy of the Asthma 3+ Visit Plan in preventing ED presentations and re-presentations with asthma, recently confirmed in children, is yet to be confirmed in adults.23

Overall, our detailed analysis of recurrent hospital ED attendees suggests that emergency department presentation was appropriate for most reattendees with severe chronic asthma, at least on the index presentation. Remediable factors exist in only a third of cases. Solutions primarily involve removing barriers to medical care and improving asthma education. Our findings further indicate the important role of respiratory infections in this group and emphasise the need for a prospective study to inform clinical use of short courses of oral corticosteroids in infective exacerbations of asthma, compared with continued or increased maintenance therapy with inhaled corticosteroids.