1. Enhancing the effectiveness of health care for Ontarians through research Impact of Emergency Department Asthma Management Strategies on Return Visits in Children: A Population Based Study Astrid Guttmann 1,2,3,4 Brandon Zagorski 1 Michael Schull 1,4,5 Asma Razzaq 1 Geoff Anderson 1,4 1 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. 2 Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario 3 Department of Paediatrics, Faculty of Medicine, University of Toronto 4 Department of Health Policy, Management and Evaluation, University of Toronto 5 Department of Emergency Medicine, University of Toronto

2. Disclosures Research funded by the Ontario Hospital Report Research Collaborative Salary Support for Dr.’s Austin and Guttmann from the Canadian Institute for Health Research No conflicts to declare

3. Background Emergency Departments (EDs) play an important role in the care of children with asthma Steady rise in ED visits for asthma  >750,000 visits in US (2004) Many guidelines for overall management of acute exacerbations ? Best strategies for implementing guideline care

4. Research Objectives 1) Describe the current asthma management strategies for children employed by EDs in the province of Ontario 2) Test which strategies have an impact on 72 hour return visits in children -- performance measure

5. Methods Population-based cohort study  Comprehensive administrative heath and survey data from all 152 EDs in Ontario, Canada  Cohort: all children ages 2 - 17 years who had a visit to an ED for asthma (April 2003 to March 2005)  Outcome: Unplanned return visit within 72 hours

6. ED Resources and Asthma Management Strategies ED Survey  Training of frontline staff  Pediatrician for consultation  Short stay unit  Guidelines  Preprinted, standardized order sheet  Discharge instructions  Trained personnel in asthma education  Routine PFTs  Dispense aerochambers

7. Analysis Clustered logistic regression model (GEE) controlling for  patient factors age, gender, SES, triage score, history of admission  hospital factors propensity to admit, type (academic, large and small community), volume of asthma patients (all ages)  Subgroup Analyses Training of frontline staff PFTs

8. Results 32, 996 children with at least one visit for asthma in the 2 year study period Academic and large community hospitals tended to see younger and sicker children Overall return visit rate 5.6% (7.1% in the small community hospitals) Subsequent admission rate of 16.6% in those returning

9. Distribution of Emergency Department Strategies and Resources by Hospital Type * Hospital Type Number of Strategies Academic (N=12) Large Community (N=70) Small Community (N=70) All (N=152) None03 (4.3)1 (1.4)4 (2.6) Up to 2 Strategies 4 (33.3)8 (11)23 (32.9)35 (23) 3-4 Strategies4 (33.3)32 (46)33 (47.1)69 (45.4) 5 or more Strategies 4 (33.3)27 (39)23 (18.6)44 (28.9) * 100% response rate

10. Adjusted Odds Ratios of Return Visits by Hospital Strategy/Resources Hospital Strategy/ResourcesOdds Ratio (95%CI) p Value Short stay unit1.17 (0.99, 1.38)0.06 Access to a Pediatrician0.64 (0.52, 0.79)<0.001 Pre-printed discharge instructions0.99 (0.83, 1.19)0.95 Pre-printed order sheets0.68 (0.55, 0.85)< 0.001 Routine use of peak flow testing0.93 (0.79, 1.10)0.40 Trained personnel in asthma teaching 0.96(0.78,1.18)0.68 Ability to dispense aerochambers0.87 (0.70, 1.08)0.21 Availability of asthma guidelines0.96 (0.80, 1.16)0.70

11. Return Visit Rate by Number of Effective Strategies* Used StrategiesHospitals with the Number of Key Strategies (N=152) Return Visit Rate (%) No.(%) Neither95(63)6.9 Pediatrician for Consultation only 31(20) 5.4** Order Sheet Only9(6) 5.4*** Both17(11) 4.4** *Access to pediatricians, pre-printed order sheets ** p<0.001 ***p<0.05

12. Main Findings 2 Strategies associated with reduced recidivism  Preprinted, standardized order pathway  Access to pediatricians No difference between EDs with pediatrician as frontline physicians vs those available for consults

13. Mechanism of effect of strategies Standardized order sheets  Dosing of appropriate medications  Assessment criteria  Follow up plans Access to pediatrician for consultation  ?guideline care, more time for teaching/counselling?

14. Limitations No verification of survey data Did not account for follow up Testing different constructs  Order sheets, discharge instructions Ecologic exposures  Pediatrician, PFT’s

15. Strengths and Conclusions Complete response rate Population-based sample of children across different settings/providers Effectiveness of interventions Pre-printed/standardized order sheet  Feasible, inexpensive  Currently only used by minority of EDs