Comparing Three Ways to Prepare Children and Caregivers to Manage Asthma after an Emergency Room Visit – The CHICAGO Trial

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What was the research about?

Asthma affects 1 in 10 children in the United States. When asthma isn’t managed well, children may need treatment in an emergency room, or ER. Doctors in the ER can use guidelines based on research to decide how to prepare families to manage asthma after they go home.

This study compared three ways to prepare children and caregivers to manage asthma after they leave the ER:

• Guideline-based, ER only. In this approach, the children and caregivers received instructions in the ER about how to use their medicines and inhalers. Afterward, ER staff set up follow-up office visits.
• Guideline-based, ER plus home visits. In addition to the meeting in the ER, children received up to five at-home visits from a community health worker who reviewed information and instructions from the ER meeting.
• Enhanced usual care. Children received the care usually provided in the ER, plus education on how to use their inhalers. Children also received two free inhaler spacers. A spacer is a tube that holds the medicine in place so that it’s easier to breathe in.

What were the results?

The three ways of preparing families to manage asthma at home didn’t make a difference in how families said asthma affected their lives, such as whether children had trouble breathing or if caregivers could work. However, compared with children who received enhanced usual care, children who received guideline-based care in the ER—with or without home visits—were more likely to

• Use medicine at home, including steroids, inhaler medicine, and rescue medicine
• Schedule an office visit

Children who received at-home visits were more likely to fill prescriptions and go to the office visit than children who received guideline-based care in the ER only or enhanced usual care.

Who was in the study?

The study included 373 children ages 5 to 11 who received care at six hospitals in Chicago. Of these children, 64 percent were black, and 31 percent were Hispanic or Latino. The average age was 7, and 67 percent were boys. Eighty percent had public insurance.

What did the research team do?

The research team assigned children, by chance, to receive one of three types of care. During the ER visit and six months later, the team asked children and caregivers to fill out a survey about how asthma affected their lives. The team also looked at patients’ health and pharmacy records to find out how often

• Children got an appointment for an office visit
• Children went to the office visit
• Children got prescriptions for asthma medicine before leaving the ER
• Caregivers filled children’s prescriptions

Doctors, community health workers, public health officials, people with asthma, and caregivers of children with asthma helped plan the study.

What were the limits of the study?

The research team enrolled fewer children in the study than planned. In addition, only 63 percent of children completed the six-month study. Results may have been different if more children had enrolled in or completed the study.

Future research could look at how guideline-based meetings and the use of community health workers affect children and caregiver’s lives with more people in different locations.

How can people use the results?

Hospital staff and doctors can consider the results when planning ways to help children and caregivers manage asthma at home after going to the ER.

Objective

To compare three discharge approaches for preparing children with uncontrolled asthma treated in the emergency department (ED) and their caregivers to manage asthma

Study Design

This multicenter trial compared three discharge approaches for children who present with uncontrolled asthma in the ED:

• Guideline-based, ED-only discharge instructions. Clinicians provided structured, guideline-based discharge instructions to children and caregivers in the ED. Children and caregivers received training on appropriate use of quick-relief medication and daily and systemic corticosteroids, how to avoid asthma triggers, and recognizing symptoms that require medical attention. Staff also scheduled a follow-up appointment for the children.
• Guideline-based ED discharge instructions plus home visits. In addition to the guideline-based discharge instructions provided in the ED, children received up to five at-home visits over six months from a community health worker to help implement discharge instructions.
• Enhanced usual care. Children and caregivers received usual ED care plus two free inhaler spacers and education about inhaler techniques.

Participants in the study received care at six clinical centers in Chicago. The research team randomized 373 children ages 5–11 to one of the three interventions. Of the children, 64% were black, and 31% were Hispanic or Latino. The children’s average age was 7, 67% were male, and 80% had public insurance.

During the initial ED visit and six months later, the research team surveyed children and caregivers about the effect of asthma on their lives, such as whether children had trouble breathing or if caregivers could work. The team also reviewed patient records and pharmacy data.

Clinicians, community health workers, public health officials, individuals with asthma, and caregivers of children with asthma helped plan the interventions and select outcomes.

Results

Asthma’s effect on the lives of children or caregivers did not differ across the three groups. However, compared with children receiving enhanced usual care, children in the two groups who received the guidelines-based ED discharge instructions were more likely to

• Use systemic corticosteroids at home (p<0.0001 for both groups)
• Use inhaled corticosteroids at home (p<0.001 for both groups)
• Use inhaled rescue medications at home (p<0.001 for both groups)
• Receive a follow-up appointment within four weeks of ED discharge (p<0.00001 for both groups)

Children in the ED plus home visits group were more likely to have prescriptions filled within seven days of ED discharge than the ED-only or enhanced usual care groups (p<0.001). Children in the ED plus home visits group were more likely to attend follow-up appointments than children in the enhanced usual care group (p=0.0005), but not the ED-only group.

Limitations

The research team was unable to enroll as many participants as planned, and only 63% of children remained in the study at six months, limiting the statistical power of the analyses.

Conclusions and Relevance

Providing guideline-based discharge instructions in the ED did not change the effect of asthma on children or caregivers’ lives compared with usual care. However, children who received guideline-based discharge instructions in the ED were more likely to fill prescriptions for asthma-controlling medications and to report using those medications at home.

Future Research Needs

Future research could further examine the impact of guideline-based discharge instructions and use of community health workers on children and caregivers’ lives, with a larger sample and in other geographic locations.