Direct concurrent comparison of multiple pediatric acute asthma scoring instruments

ABSTRACT

Objective: Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED. Methods: Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2–18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization. Results: Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21–0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054). Conclusions: We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.

Keywords:

• Asthma
• child
• emergency service (hospital)
• hospitalization
• decision making
• validation studies

What is known on this subject

Numerous scoring instruments of acute asthma severity are used in emergency departments to assess children with acute asthma and deliver treatment. However, selection of instruments for clinical care remains arbitrary and the optimal instrument is unknown.

What this study adds

We report a method that facilitates direct, blinded comparison of multiple scoring instruments of acute asthma severity. Using this method, tested scoring instruments are shown to vary in their predictive ability for hospitalization.

Financial disclosure

There are no financial relationships relevant to this work for any authors.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding

This investigation was supported by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764).

Contributor's statement

Dr. Johnson conceptualized and designed the study, drafted all data collection instruments, directed all aspects of data collection, verified the fidelity of data entry, contributed substantially to analysis planning, assisted with analysis, wrote the first and subsequent drafts of the manuscript, and approved the final manuscript submitted. Dr. Nkoy contributed substantially to the conceptualization and design of the study and critically revised manuscript drafts. Dr. Sheng contributed substantially to analysis planning, analyzed study data, drafted portions of the manuscript, and reviewed and refined manuscript drafts. Dr. Greene contributed substantially to the design of the study and to analysis planning, and reviewed and refined manuscript drafts. Dr. Stone contributed substantially to the conceptualization and design of the study and critically revised manuscript drafts. Dr. Garvin contributed substantially to the conceptualization and design of the study and critically revised manuscript drafts.