Asthma sending more kids back to hospital

Readmissions are rising, reflecting gaps in care and putting a burden on the health system and parents.

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One in three children with asthma are readmitted to hospital within a year after their first admission, compared to one in five only a decade ago, a Victorian study has found.

The researchers blamed gaps in care for the rise. This included a lack of knowledge among some parents of correct inhaler technique and medication, a lack of follow-up appointments booked at discharge and guideline-discordant care.

The study, published in the Journal of Asthma, recruited almost 800 children aged three to 16 who were admitted to one of three Victorian hospitals for asthma between 2017 and 2018.

Within 12 months of their first admission, 34% of the children had been readmitted, and 69% of those were aged between three and five. That compared with hospital readmission rates of 20% a decade earlier.

However, less than 10% were readmitted within 30 days, highlighting the importance of ongoing community care and long-term asthma control, the authors wrote.

Most asthma hospital presentations were preventable, and there were several factors driving the increase in re-admission rates, said lead author Dr Katherine Chen from Murdoch Children’s Research Institute.

“Our study highlighted gaps in the children’s asthma care throughout their care journey such as reviewing their baseline asthma control, inhaler technique and asthma medication, lack of booked follow-up arrangements before discharge, and guideline-discordant care,” Dr Chen told The Medical Republic.

Dr Chen said each asthma hospital admission should be treated as a “lung attack” – similar to how heart attacks are treated – and have a holistic evaluation.

“Our research suggests that hospital specialists need to take leadership in child asthma care and start a preventative treatment if indicated at discharge, rather than leave it to the GP, who may not be as confident in caring for children with severe asthma exacerbations,” she said.

“Hospital specialists need to provide a care plan on leaving the hospital on who is going to provide follow-up, review the diagnosis, and a tailored action plan for that child for their next exacerbation.”

Dr Chen said 40% of the GP’s self-reported practices which were not concordant with National Asthma Council guidelines, and this was associated with an increased rate of readmissions for the children they cared for. 

It would also be helpful for parents to regularly review their child’s asthma control, risk minimisation and the asthma action plan with their GP or specialists, as the clinical course of asthma does change over time, Dr Chen said.

“Hospital readmission is an important marker of poorly controlled asthma in paediatric asthma care,” said Dr Nusrat Homaira, respiratory epidemiologist at Sydney Children’s Hospital and senior lecturer at the University of NSW.

“What we know from other studies in international settings into readmission is that 40-50% of kids who come to hospital with asthma are subsequently readmitted,” said Dr Homaira, who was not involved in the study.

“It’s a huge cost to the health system and a burden to parents and carers.”

The researchers said there were gaps in documented hospital care. The study found that more than a third of children had not had a review of their inhaler technique, a quarter had no documentation of an asthma education review, and three quarters were discharged without preventer medication. More than 80% of children did not have a follow-up appointment booked at the hospital.

“Only around a quarter of participants were either prescribed a preventer or asked to continue preventer use following the index admission in our study,” the researchers wrote.

“This highlights a missed opportunity for improving asthma control among primary school-aged children.”

And while most GPs said they provided asthma action plans and were aware of asthma guidelines, more than 40% of GPs reported guideline-discordant care.

Dr Homaira said key interventions that could prevent asthma readmission included enhanced coordination between acute, primary and community-based services, so a child’s primary care provider and school or childcare service were aware of the hospital admission.

It would also be helpful for children and families to have standardised written asthma action plans, to ensure they were able to understand the asthma action plan and how to use their inhaler, have access to asthma education and have regular follow-up visits with their primary care providers, she said.

“Rather than putting the responsibility on families, there needs to be a system so that the GP is alerted when the child is admitted to hospital so they can organise a follow-up visit,” she said.

Dr Homaira led a pilot study at Sydney Children’s Hospital which aimed to improve asthma management and engagement with GPs. It found readmissions could be reduced by providing key information to patients on discharge.

When children with asthma were discharged, they were given an “asthma discharge pack” including the child’s individual asthma action plan, discharge information, asthma educational resources and a letter for their GP.

“Our pilot study showed we could reduce the number of children with asthma coming to the emergency department by 60% in the following 12 months,” Dr Homaira said.

That model of care has since become routine clinical practice at the hospital.

It was helpful to remind parents that asthma was a chronic condition and children need active follow-up even when symptom-free, Dr Homaira said.

“It’s important that children have regular follow-up visits with their doctor, that parents understand the asthma action plan, and parents and children understand how to use the inhaler,” she said.

“Primary care providers can remind children and parents that they should go for their follow-up every three months regardless of symptoms.

“Asthma is a dynamic disease and no one solution will solve it. There needs to be a suite of complementary approaches involving all stakeholders who are providing care for children with asthma.”

Journal of Asthma 2022, online 24 June