Asthma

High readmission rates for childhood asthma show need for new approach


High hospital readmission rates for paediatric asthma show the need to treat exacerbations as ‘lung attacks’ and with similar thorough follow up as heart attacks, Australian specialists say.

One third of children admitted to hospital for asthma in Victoria were readmitted within a year, raising concerns about continuity of asthma management in community care, according to clinicians at The Royal Children’s Hospital and the Murdoch Children’s Research Institute in Melbourne.

Their new study published in the Journal of Asthma  found 34.3% of the 767 children aged between three years and 18 years who were hospitalised throughout a 12-month period, had to return to hospital within a year for their asthma symptoms.

Notably, the analysis found children were 57% more likely to be readmitted when their general practitioners self-reported asthma management practices that did not adhere to recommended guidelines.

Authors said the study highlighted the increased burden of asthma readmissions compared to a decade ago, when about one in five young people were found to require readmission.

“Consistent with our hypothesis, our study highlighted gaps in the children’s asthma care throughout their care journey such as reviewing their baseline asthma control, inhaler technique and asthma medication, lack of booked follow-up arrangements before discharge, and guideline discordant care,” the study said.

Lead author Dr Katherine Chen told the limbic the reasons driving the increased re-admission rates were multifactorial, but said there were gaps in hospital and community care.

“Based on medical record documentation, for one-third of children there was no documentation of a review of their inhaler technique, one-quarter did not have documentation that hospital clinicians reviewed their asthma education, and quite a big proportion, three-quarters, left the hospital without a preventative treatment,” she said. “That is quite a big proportion after a severe exacerbation requiring hospitalisation.”

She pointed to previous research published in that found families reported they had fragmented care, unclear pathways for follow up care, inconsistent advice and a lack of personalised advice, among a range of concerns after a hospital admission for asthma.

The newly published research assessed rates of hospital readmission and emergency department re-presentation for asthma within a 12-month period, using validated diagnosis information from three different hospitals in Victoria from 2017 to 2018.

Each young person was followed up, with consent, for 12 months from their initial admission. Information from the primary caregiver was included about home environmental risk factors, such as mould, exposure to cigarette smoke and water damage, as well as socio-economic status and education level.

Further, the researchers followed up the young people’s GP to survey them about their asthma management practices and assessed that against the National Asthma Council Australia guidelines.

Pre-schoolers risk

Researchers found pre-school aged children were particularly vulnerable to readmission within a year. Of the 263 young people who returned to hospital, 69.2% of them were aged between three and five years. About one in four (26.2%) were aged between six and 11 years.

Rates were consistent across the hospitals, which ranged from a tertiary facility to a mixed metropolitan paediatric and adult centre, and a regional hospital.

Home-environment factors were not considered associated with readmissions, however, researchers said the outcome “confirmed the important role of the GP in the management of paediatric asthma”.

“While most GPs reported that they provide asthma action plans and were aware of local and international guidelines, over 40% of GPs reported guideline-discordant care for questions about children with persistent asthma,” the paper said.

Dr Chen said specialist clinicians in the hospital system should provide comprehensive information to families during hospital stays, with outlines for ongoing care.

“We need to treat each hospital admission for asthma … as a ‘lung attack’, similar to how we treat a heart attack, and do a holistic evaluation of asthma management,” she said.

“Our research suggests that specialists need to take leadership in child asthma care and start a preventative treatment if indicated at discharge, rather than leave it to the GP, who may not be as confident in caring for children with severe asthma exacerbations”.

“We need to provide a care plan on leaving the hospital on who is going to provide follow-up and an individualised action plan for that child for their next exacerbation. Also a plan for follow up and reviewing the diagnosis if that’s not clear at discharge.”

 

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