Missed opportunities to transition from nebulizers to inhalers during hospitalization for acute asthma: A multicenter observational study

ABSTRACT

Objective: Hospitalizations for acute asthma are thought to be highly preventable through the use of efficacious medications, though many patients have poor metered-dose inhaler (MDI) techniques, thus lessening these medications' real-world effectiveness. Teaching MDI techniques during hospitalization may therefore lead to improved outcomes. However, MDIs may be underutilized to deliver short-acting β-agonists (SABAs) in the inpatient setting, despite equivalent efficacy to nebulizer delivery. We sought to characterize delivery methods of SABAs among hospitalized patients with acute asthma to understand if there are missed opportunities for self-management education. Methods: In this secondary analysis of a cross-sectional 25-center chart review study of children and adults (ages 2–54 years) hospitalized for acute asthma across 18 states (2012–2013), we studied SABA therapy delivery methods during hospitalization and receipt of action plans and follow-up visits. Unadjusted associations were analyzed using chi-square, Fisher's exact, or Kruskal–Wallis tests. Measurements and main results: Of 987 patients, 44% received only nebulizer-SABA (children 32% vs. adults 53%; p < 0.001) during hospitalization, and 55% (children 68% vs. adults 47%; p < 0.001) received any MDI-SABA during hospitalization. Children receiving only nebulizer- vs. MDI-SABA were significantly less likely to receive individualized action plans (p < 0.001). Compared to children, adults were overall less likely to receive written plans (47% vs. 78%, p < 0.001) or to have a follow-up appointment (38% vs. 59%, p < 0.001) at discharge. Conclusions: Opportunities exist to increase the delivery of MDI-SABA during hospitalization, particularly for adult inpatients with asthma. Further studies are needed to determine if increased use of MDI-delivered therapies improves patient education and outcomes.

KEYWORDS:

• Acute asthma
• asthma exacerbation
• hospitalization
• metered-dose inhaler
• nebulizer
• short-acting β-agonist
• practice variation

Acknowledgements

We thank the MARC-37 study hospitals and research personnel for their ongoing dedication to asthma research (see prior publication) [13]. We specifically thank Darcy Denner and Nicole Woodrick for their support with extractions and chart review, and Nicole Twu for her project support.

Declaration of interest

Dr. Hasegawa has received research support from Teva. Dr. Camargo has provided asthma-related consultation for GlaxoSmithKline, Novartis, Regeneron, and Teva; and research support from Novartis. The other authors have no relevant financial relationships to disclose.

Funding

The study was funded by a grant from Novartis Pharmaceuticals Corporation to Massachusetts General Hospital (PI: Camargo); the sponsor had no role in the conduct of the study, nor collection, management, or analysis of the data. Dr. Press is currently funded by NHLBI K23 HL118151.