Interventions to Improve Outpatient Follow-Up in Children with Asthma Who Have Attended the Emergency Department: a Systematic Review and Meta-Analysis

Abstract

Background: Asthma is a leading cause of chronic disease in children associated with morbidity and mortality. There is poor adherence to outpatient follow-up after an emergency room (ED) visit for asthma, which is a key aspect of management endorsed by national guidelines. Objective: Our primary objective was to systematically review the effectiveness of professional, financial and organizational interventions initiated in the ED for asthma-related outpatient follow-up within 1 month in children aged 1 to 18 years old. Secondary outcomes were follow-up from 1 month to 1 year, ED visits, hospital admissions, controller medication use, having an asthma action plan and quality of life. Design/Methods: We performed a literature search of MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, Scopus and Science citation index up to October 2009. We included RCTs, quasi-RCTs and controlled clinical trials comparing any intervention vs. usual care in asthmatic children to improve follow-up and asthma-related outcomes after an ED visit. Methodological quality was assessed with Cochrane Collaboration's tool for assessing risk of bias. We calculated pooled relative risk with inverse variance random effects models. Results: We included 7 RCTs with a total of 1867 children. The methodology was of moderate quality in 6 trials and low in 1. Interventions were clinically heterogeneous and included assistance in making follow-up, telephone contact after the ED visit, specialized clinics, addressing beliefs/ barriers to follow-up and coaching with monetary incentives. Any intervention compared to standard care led to increased chances of outpatient follow-up within 1 month (5 trials, RR 1.40; 95% CI 1.06, 1.86). There was no statistical difference between groups for follow-up from 1 month to 1 year (1 trial), asthma-related ED visits at 1 month (2 trials, RR 0.95; 95% CI 0.77, 1.28) or 6 months (2 trials, RR 1.00; 95% CI 0.77, 1.29), asthmarelated admissions at 1 year (2 trials, RR 1.45; 95% CI 0.64, 3.28), controller medication use (3 trials, RR 0.96; 95% CI 0.88, 1.05), missed schooldays and workdays, asthma-related quality of life scores and symptoms. One trial reported more asthma action plans with the intervention. Conclusions: Moderate quality evidence supports interventions to improve outpatient follow-up within 1 month of an ED visit for childhood asthma. However, these do not necessarily lead to improved long-term outcomes.