It has been well documented that continued elevated levels of uncontrolled asthma and asthma exacerbations exert an adverse impact on overall patient asthma outcomes.  These negative impacts have been particularly hard on patients who receive care through the Indian Health Services and the overall United States Healthcare System. (Bosnic-Anticevich, Stuart, Mackson, Cvetkovski, Sainsbury, Armour, Mavritsakis, Mendrela, Travers-Mason, & Williamson, 2014). 

Systematic Review

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The aim of this systematic review is to review the current state of the science regarding pediatric asthma management after an emergency room visit for an episode of acute exacerbation.  Current research has shown conflicting evidence whether having early access to primary after an emergency room reduces rates of recidivism. Other findings show that many asthma patients do not return for a primary follow-up visit even when having universal access to care, which may further exacerbate the problem of poorly, controlled asthma (Li, To, Guttman, 2012).

To further study the scope of the problem and current research regarding this or any other potential research problem one must perform a systematic review of current literature.  A systematic review is essential to determine what research has already been done, what findings are available, and help identify areas that require further research to understand the topic at hand entirely.  Furthermore, systematic reviews can help narrow and limit the scope of the research question, determine what relevant and quality of data currently exists and will contribute to limiting focus of additional research. Lastly, and most importantly, systematic reviews are extremely useful in helping to address shortfalls in current practice and develop future practice guidelines.

The overall questions that need to be addressed are the quality of current studies regarding the relationship between primary care asthma follow-up care after emergency room visits and reduction of repeat emergency room visits. The issues of relevance to proposed study question, validity and reliability of current studies, and the pros and cons of post emergency room primary care visits are addressed here as well.

In regards to the question of reducing the burden of recurrent visits regarding acute adolescent asthma exacerbations systematic review of the current literature has shown the need for additional research.  Current research has shown conflicting evidence wither primary care follow-up, and primary intervention will limit adolescent asthma emergency room usage.  By conducting a systematic review the goal will be to determine where evidence is lacking and where further study will be beneficial.  (Dexheimer, Borycki, Chiu, Johnson, & Aronsky, 2014; Li, To, Guttman, 2012; Lougheed, 2006)

Method

The method for this systematic review will be based on the World Health Organization protocol guidelines (Andrew, 2011).  The primary focus as listed in the introduction is identifying studies, which support or refute the effectiveness of reducing recurrent pediatric asthma emergency room visit by focusing on improving primary care evaluations.

The primary population of the study is pediatric asthma patients.  The goal will be review studies based on the subpopulation of Native American children.  However, if necessity dictates the study population will be broadened to include the general pediatric population or adult asthma patients who receive care for asthma emergency room setting.

The intervention is the results of those who receive primary care after an acute asthma exacerbation with treatment in the emergency room versus those who do not.  The comparison will be the data analysis of repeat ER visits.  The expected outcome is a reduced rate of repeat or recurrent ER visits regarding an asthma exacerbation. 

The databases reviewed for applicable research will include Cochrane, CINAHL, Science Direct, and Pubmed/Medline. The following journals will be incorporated into hand-search and for relevant information and articles the American Academy of Pediatrics, the American Association of Nurse Practitioners, and the American Academy of Allergy, Asthma, and Immunology.

Studies for inclusion will focus on quantitative studies, past literature reviews, and related previous systematic studies and are prioritized on methodological quality.  No gray literature studies will be included.

            Inclusion criteria for articles selected include:

·      Articles published with publications dates of 2006-2017.

·      Published in a peer-reviewed science, medical, and nursing journal articles.

·      Initial publication in the English language

·      Articles that contain one or more of the following words in title or abstract: Adolescent Asthma Care, Asthma management in emergency room regarding reducing revisits, and Native American Asthma Care.

·      Articles that contain one or more of the following words in title or abstract: Adolescent, Pediatric, or childhood; Asthma, follow-up care, subsequent care, asthma, protocols, Emergency Room, or Primary Care.

Exclusion Criteria:

Exclusion criteria include editorials, newspaper articles, any form of popular media as previously mentioned as grey literature.

·      Search results published in books, book chapters, commentaries, or editorials.

·      Initial publication in language other than English without translation.

·      Published in non-nursing, science, or medical journals, and non-peer reviewed publications.

 

Literature Review

Five relevant studies were identified from the search process.  In the first study, Li, To, and Guttmann (2012) investigated the relationship between follow-up care visits and emergency department (ED) re-visits and hospital admissions among children.  The researchers emphasized that ED and hospitals play a significant role in providing acute asthma care to children.  They also noted that it is important to follow national and international guidelines with regards to follow-up visits to prevent relapse or hospitalization due to current or future exacerbations (Li et al., 2012).  This argument is conceivable since continuity of care is likely to minimize asthma-related ED visits.  Li et al. (2012) conducted a population-based study of children aged 2-7 years using datasets from the Institute of Clinical Evaluative Sciences.  The researchers focused on primary and secondary outcomes, such as hospital admission for asthma and follow up visits within 28 days.  A cohort of 29,391 children was used in the study, out of which 33% had at least one follow-up visit within 28 days (Li et al., 2012).  The findings indicated that most of the visits occurred within the first week and day.  The number of follow-up visits ranged from 0 to 9.  The factors associated with the visits included age, gender (male), income, high acuity, and prior hospitalization for asthma.  Moreover, 22.1% of the children were readmitted with 29-365 days, with the number of visits to the ED ranging from 0-16.  The findings indicated that follow-up was not significantly correlated with ED-visits or hospitalization.  The study further established that ED re-visits were more likely to occur among younger children, individuals from lower income quintile, patients suffering from acute and chronic ailments, and those with a history of admission.  Li et al. (2012) noted that children who had visited the ED at least once in the past two years were two times more likely to relapse.  The researchers emphasized the need to focus on quality as well as continuity of patient care to improve the asthmatic patients’ outcomes.

In the second study, Smiley, Sicignano, Rush, Lee, and Allen (2016) investigated the outcomes of follow-up care among asthmatics who visit an emergency department in the military health system.  According to the National Asthma Education and Prevention Program (NAEPP) guidelines, follow-up should be conducted within 28 days after visiting an ED to offset the possibility of asthmatic attacks.  Optimization of controller management is one of the most important elements of the follow-up visit.  Smiley et al. (2016) examined the characteristics linked with improved outcomes, such as medication information, which have been overlooked in many studies.  The researchers hypothesized that medication information could be a crucial indicator of effective asthma follow-up visits.  The retrospective observational cohort study was conducted among children aged between 2 and 17.  The data was retrieved from the Department of Defense (DoD) Military Health System (MHS).  The researchers utilized a sample of 10,460 patients.  The findings indicated that almost half (47.5%) of the patients complied with post-primary care follow-ups, although most of them visited the hospital once.  The study did not establish a relationship between follow-up and characteristics such as patients’ gender, geographic location, and season or source of ED visit.  However, the researchers observed that 24% of the patients without a follow-up revisited the ED between 29-365 days compared with 21.1% of those who had complied with the follow-ups.  The median time for the revisit was 156 and 159 days respectively.  Moreover, hospitalization for the disease was noted among 2.2% and 2.3% of the patients who did not attend follow-up and those who did respectively.  The findings indicated that a follow-up visit minimized the probability of experiencing an ED re-visit in the following year.  The study further established that those who had experienced a follow-up had a greater Asthma Medication Ratio (AMR) compared with those who did not.

In the third study, Kao and Wu (2017) focused on the effect of continuity of care on ED visits among elderly, asthmatic patients in Taiwan.  The researchers observed a positive correlation between continuity of care and health care outcomes.  However, they noted paucity of studies focusing on the impact of COC on emergency-related ED visits among elderly patients.  The researchers conducted a retrospective cohort study using data from Taiwan’s health insurance claims database.  The COC index was utilized to assess the number of physicians that a patient had visited in the first year and the asthma-related ED visits in the following year.  Cox model was used to determine the hazard ratio between COC and ED visits.  A sample of 3395 patients was used in the study with an overall mean COC of 0.73.  The findings indicated that 48.5% of the patients had a perfect COC (COCI=1).  Besides, the patients with low COC had a higher risk of experiencing an asthma-related ED visits compared with the subjects with perfect COC.  The findings also showed that asthmatic attacks were more likely to recur among elderly patients with lower COC.

In the fourth study, Huang, Wu, Hung, and Lin (2016) explored the impacts of continuity of care on emergency department utilization among children with asthma in Taiwan.  The researchers hypothesized that higher continuity of ambulatory asthma care significantly minimizes the risk of asthma-specific ED visits.  However, they argued that COC has not been investigated among Asian asthmatic children.  The researchers conducted a retrospective cohort study using the Taiwan National Health Insurance Dataset for the period between 2006 and 2009.  The study focused on new asthmatics aged between 0-17, and each case was observed for two years.  A sample of 29, 277 patients was used for the study purposes.  COCI was adopted to calculate continuity of ambulatory asthma care and asthma-specific ED utilization in the first and second year respectively.  The findings indicated that the patients had an average COCI of 0.68, with 42.3% of the patients having an index of 1.  Additionally, 1641 patients had experienced at least 1 asthma-related ED visit.  The findings further showed that the patients with medium and low continuity of ambulatory asthma care experienced higher asthma-related ED visits (21% and 38% respectively).  Huang et al. (2016) concluded that high continuity of ambulatory asthma care could minimize these visits among newly diagnosed children.  The researchers encouraged healthcare providers to emphasize the importance of follow-up care with the aim of improving health outcomes.

In the fifth study, Fontes et al. (2011) investigated the impact of asthma management program on hospitalization as well as emergency department visits.  The researchers argued that there is a need to promote treatment among asthmatic patients who regularly visit the ED.  To this end, the Wheezing Child Program has been implemented in Brazil to combat asthma in the country.  Foster et al. (2011) explored the program’s effect on hospitalizations and ED visits among children and adolescents who have been enrolled in the program for a year.  The researchers established that 1,065 of the patients had received follow-up care for at least 12 months.  However, only a sample of 608 patients could be used in the study.  The findings indicated that hospitalization and ED visits were common (89.8%) before implementation of the program.  Additionally, 11.9% of the patients were hospitalized between 4 and 15 times before the program implementation, whereas 53% of them had visited ED up to 25 times.  A significant reduction in hospitalization and ED visits was noted after the implementation of the Wheezing Child Program.  In fact, only 20.8% of the patients were hospitalized and the number of hospitalizations did not exceed four.  Similarly, only 50.8% of the patients made ED visits, with 5.3% of the subjects requiring more than 5 of such visits.  Linear regression modeling indicated a mean reduction of one and 0.13 ED visit and hospitalization per month.  The researchers concluded that the program minimized the frequency of hospitalizations and ED visits.

Conclusion

            The reviewed studies indicate a positive relationship between follow-up care and improved patient outcomes.  Specifically, the findings from the studies show that follow-up care reduces hospitalization and ED visits.  Particularly, this type of care should be provided within 28 days, as per NAEPP guidelines, in order to maximize the clinical and patient outcomes.  The findings further emphasize the importance of follow-up care among asthmatic patients.  Markedly, asthmatic adolescents should be encouraged to use follow-up care services in order to reduce the probability of re-hospitalization and ED visits.  Healthcare providers should also be encouraged to adopt measures for promoting continued care among teenagers and adolescents.