Chest
Volume 127, Issue 5, May 2005, Pages 1579-1586
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Clinical Investigations
Asthma Exacerbations in North American Adults: Who Are the “Frequent Fliers” in the Emergency Department?

https://doi.org/10.1378/chest.127.5.1579Get rights and content

Objective

To characterize adult asthma patients according to frequency of emergency department (ED) visits in the past year.

Design

Adults presenting with acute asthma to 83 US EDs underwent structured interviews in the ED and by telephone 2 weeks later.

Results

The 3,151 enrolled patients were classified into four groups: those reporting no ED visits in the past year (27%), one to two visits (27%), three to five visits (25%), and six or more visits (21%). The number of ED visits (NEDV) was associated with older age, nonwhite race, lower socioeconomic status, and several markers of chronic asthma severity (all p < 0.001). NEDV was strongly associated with Medicaid insurance (17% among those with no visits, 22% with one to two visits, 30% with three to five visits, 39% with six or more visits; p < 0.001). NEDV was unrelated to gender or having a primary care provider (PCP). In a multivariate model, independent predictors of high ED use (six or more visits a year) were nonwhite race, Medicaid, other public, and no insurance, and markers of chronic asthma severity. Patients with six or more ED visits accounted for 67% of all prior ED visits in the past year.

Conclusions

High NEDV is associated with characteristics that may help with identification of “frequent fliers” in the ED. A better understanding of these characteristics may advance ongoing efforts to decrease asthma health-care disparities, including differential access to primary asthma care. National guidelines recommend specific ED treatments then referral to a PCP. Although longitudinal care is surely important, attempts to reduce frequent ED asthma visits may be better directed toward more specific preventive and educational needs.

Section snippets

Materials and Methods

The present analysis combined data from four prospective cohort studies performed during 1996 to 2001, as part of the Multicenter Airway Research Collaboration (MARC). MARC is part of the Emergency Medicine Network (EMNet), a collaboration with > 160 participating EDs.11 Using a standardized protocol, investigators at 83 EDs in 26 US states enrolled patients 24 h/d for a median of 2 weeks. The Institutional Review Board at each of the 83 participating hospitals approved the study, and informed

Results

Of 3,257 asthmatic patients enrolled, 3,151 patients (97%) had data on NEDV and were included in the current analysis. Eight hundred sixty-three patients (27%) reported no prior ED visits, while 843 patients (27%) had one to two visits, 791 patients (25%) had three to five visits, and 654 patients (21%) had six or more visits in the past year. Figure 1 depicts the cumulative number of ED visits during the prior year in each of these four frequency groups. Patients with one to two visits (n =

Discussion

To our knowledge, this is the first large, multicenter study that characterizes asthma patients who frequently utilize the ED for their asthma care. The data were drawn from > 3,000 patients in 83 US EDs. Based on the diversity of these sites, and similar results from previous smaller-scale studies,1415 we believe that our findings can be generalized to other EDs and may help to identify and target adult asthma patients with very frequent use of the ED for their asthma care.

To date, most

Summary

Patients with high NEDV were more likely to be nonwhite, of lower socioeconomic status, have Medicaid insurance, and have higher chronic asthma severity. Patients with six or more ED visits accounted for 20% of consecutive ED patients with acute asthma, and 68% of all prior ED visits in the past year. National guidelines recommend specific ED treatments followed by referral to PCP, with unclear recommendations about if and when to refer patients to asthma specialists. We found no relation

Appendix EMNet Steering Committee

Edwin D. Boudreaux, PhD; Barry E. Brenner, MD, PhD; Carlos A. Camargo, Jr., MD (Chair); Rita K. Cydulka, MD; Theodore J. Gaeta, DO, MPH; and Michael S. Radeos, MD, MPH.

EMNet Coordinating Center

Carlos A. Camargo, Jr., MD (Director); Sunday Clark, MPH; Lisa A. Dubois; Sunghye Kim, MD, MSc; Sarah N. Kunz; Andrea J. Pelletier, MS, MPH; Elizabeth Portnoy; Ilana B. Richman; Ashley F. Sullivan, MS, MPH; all at Massachusetts General Hospital, Boston, MA.

Principal Investigators at the 83 Participating Sites

G. Almond (Metropolitan Hospital Center, New York, NY); G. Almond and D. Feingold (Our Lady of Mercy Medical Center, Bronx, NY); F.C. Baker III (Maine Medical Center, Portland, ME); J.M. Baren (Children's Hospital of Philadelphia, Philadelphia, PA); J.M. Baren, S. Stahmer (Hospital of the University of Pennsylvania, Philadelphia, PA); J.M. Basior (Buffalo General Hospital, Buffalo, NY); B. Bauman (Oregon Health Sciences University Hospital, Portland, OR); R.S. Benenson (York Hospital, York,

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    Ms. Clark is supported by grant T32 ES07069 and Dr. Camargo is supported by grant HL63841 from the National Institutes of Health. The cohort studies were supported by unrestricted grants from GlaxoSmithKline (Research Triangle Park, NC).

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestjournal.org/misc/reprints.shtml).

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