Reasons and outcomes for patients receiving ICS/LABA agents prior to, and one month after, emergency department presentations for acute asthma

Abstract

Objective: Asthma is a common emergency department (ED) presentation. This study examined factors associated with inhaled corticosteroids/long-acting beta-agonist (ICS/LABA) use; and management and outcomes before and after ED presentation. Methods: Secondary analysis of a prospective cohort study; adults treated for acute asthma in Canadian EDs underwent a structured interview before discharge and were followed-up four weeks later. Patients received oral corticosteroids (OCS) at discharge and, at physician discretion, most received ICS or ICS/LABA inhaled agents. Analyses focused on ICS/LABA vs “other” treatment groups at ED presentation. Results: Of 807 enrolled patients, 33% reported receiving ICS/LABA at ED presentation; 62% were female, median age was 31 years. Factors independently associated with ICS/LABA treatment prior to ED presentation were: having an asthma action plan; using an asthma diary/peak flow meter; influenza immunization; not using the ED as usual site for prescriptions; ever using OCS and currently using ICS. Patients were treated similarly in the ED and at discharge; however, relapse was higher in the ICS/LABA group, even after adjustment. Conclusion: One-third of patients presenting to the ED with acute asthma were already receiving ICS/LABA agents; this treatment was independently associated with preventive measures. While ICS/LABA management improves control of chronic asthma, patients using these agents who develop acute asthma reflect higher severity and increased risk of future relapse.

Keywords:

• Asthma
• emergency department
• management

Acknowledgements

BHR takes responsibility for the content of the manuscript, including the analysis and interpretation of the data. CVR confirms that the study objectives and procedures are honestly disclosed. She confirms that the procedures listed in the study protocol approved by the Institutional Health Research Ethics Board were followed to an extent that the results are valid and generalizable to a population similar to that enrolled in this study. Finally, CVR personally reviewed and led the analysis/interpretation of study data and wrote the draft of the final manuscript. BB, SRM, ME, SC, MS, RAL, IGS, SA and AS supported the design and conduct of the study, understand the statistical methods employed for the analyses and the generalizability of the results. They all made substantial contributions to the final manuscript. All authors reviewed and approved the final version of the manuscript for publication. The authors would like to thank the Canadian Institutes of Health Research (CIHR; Ottawa, ON) and the Medical Services Incorporated Foundation (MSI; Edmonton, AB) who provided research funding for this study; and the Department of Emergency Medicine Research Group (EMeRG) at the University of Alberta for their in-kind support of this project. The funders take no responsibility for the conduct, analyses and interpretation of these results. The research team would like to thank Sandra Blitz for her assistance during the study design; the Epidemiology Coordinating and Research Center (EPICORE; Edmonton, AB) for their support in data management and coordination; and the following AIR investigators (in order of recruitment numbers): Duncan Mackey (Lethbridge, AB), Brian Rowe (Edmonton, AB), Alan Walker (Edmonton, AB), Scott Ross (St. Albert, AB), Ian Stiell (Ottawa, ON), Bryan Young (Calgary, AB), Sam Campbell (Halifax, NS), Marco Sivilotti (Kingston, ON), Bjug Borgundvaag (Toronto, ON), Chris Boule (Mississauga, ON), Robert Stenstrom (Vancouver, BC), Andrew Worster (Hamilton, ON), Shaun Visser (Thunder Bay, ON), Eddy Lang/Marc Afilalo (Montreal, PQ), Riyad Abu-Laban (Vancouver, BC), Jhon Froh (Saskatoon, SK), Marcel Emond (Quebec, QC), Jacques Lee (Toronto, ON), and Chantal Guimont (Ste-Foy, Quebec). The authors would also like to express their gratitude to the following research staff for their assistance in site coordination (in order of recruitment): Marlene Myles, Ginny Willis, Leslie Tyler, Debbie Boyko, Michelle Pachal, Cathy Clement, Renee Vineff, Agnieszka Grabowski-Comeau, kathy Bowes, Michelle Loftus, Sharon Oliveros, Crystal-Anne Smith, Barbara Boychuck, Christina Brean, Sandra Stoger, Cristina Ciolofan, Jan Buchanan, Tricia Pearson, Cynthia Reich, Patricia Chabot, Shana Huntly and Annie-Claude D’Anjou.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Dr. Rowe is supported by CIHR through a Tier I Canada Research Chair in Evidence-based Emergency Medicine from the Government of Canada (Ottawa, Ontario). Dr. Villa-Roel was supported by CIHR in partnership with the Knowledge Translation branch. Prior to his death, Dr. Majumdar was a Health Scholar of the Alberta Heritage Foundation and Alberta Innovates Health Solutions (AIHS) and held the Endowed Chair in Patient Health Management of the Faculties of Medicine and Dentistry and Pharmacy and Pharmaceutical Sciences, University of Alberta (Edmonton, Alberta, Canada).