Low Rates of Controller Medication Initiation and Outpatient Follow-up After Emergency Department Visits for Asthma

Abstract

To determine what proportion of patients who are seen in the emergency department (ED) for asthma receive inhaled corticosteroids (ICSs) or attend follow-up appointments.The sample included a total of 3435 patients in the South Carolina Medicaid database between 2007–2009 aged 2 to 18 years with an ED visit for asthma. Patients who were in the top 99th percentile for total number of ED visits, had been admitted for asthma, or had an ICS claim in the 2 months preceding the ED visit were excluded.The study was a retrospective cohort analysis. The diagnosis of asthma was identified by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. ED visits were identified by using Current Procedural Terminology codes and by an ED flag provided in the data set. Pharmacy claims filled were examined to identify ICSs, ICSs/long-acting β-agonists, and leukotriene modifiers. The primary and secondary outcomes were a pharmacy claim for any ICS or ICS/long-acting β-agonist during the month of or the month after the ED visit and any outpatient visit with a primary diagnosis of asthma within 2 months after the ED visit, respectively. Data on gender, age, race, rural residence, and asthma severity also were collected.Only 18% of the patients filled a prescription for an ICS during either the month of or the month after the ED visit, and only 12% of patients attended an outpatient follow-up appointment within the 2 months after the ED visit. In addition, only 5.2% of patients received an ICS and attended a follow-up visit for asthma. Patients aged 7 to 12 years were more likely to receive ICSs or leukotriene modifiers and attend follow-up appointments than those aged 2 to 6 or 13 to 18 years. Patients with severe asthma, as defined by ≥6 pharmacy claims for short-acting β-agonists in the calendar year of the ED visit, were more likely to receive ICSs, to receive ICSs or leukotriene modifiers, to attend follow-up appointments, and to attend follow-up appointments and receive ICSs.This study clearly demonstrates that most children in the South Carolina Medicaid population with asthma treated in the ED for an asthma exacerbation do not receive appropriate preventive care, including filling a prescription for an ICS and attending outpatient follow-up appointments.As has been demonstrated previously, this study shows that the rate of follow-up and the use of asthma controller medications after an ED visit for an asthma exacerbation are quite poor. The authors were unable to determine if ED physicians were not prescribing controller medications, if patients were not having prescriptions filled, or if a combination of factors led to a lack of controller medication use. The Medicaid population frequently uses the ED for primary care–related issues, and this study shows that measures aimed at preventing ED visits for asthma exacerbations are not being addressed adequately. Authors of future studies may consider investigating the role of the ED physician in prescribing asthma controller medications and strategies for improving adherence in this patient population.