Inhaled Corticosteroid Prescriptions in the ED for Recurrent Asthma Using IT Clinical Decision Support: Revisit After Cessation of an Incentive Program

Background: Asthma is a leading chronic illness of childhood, with significant morbidity and substantial impact on health resources utilization. In 2011, asthma was the primary diagnosis for 1.8 million United States emergency department (ED) visits among both children and adults, with asthma being the third leading cause of hospitalization among children.

Since asthma is episodic, many patients do not seek care until symptoms of an asthma exacerbation occur, and as many as 37% of children return to the ED within 6 months of their initial ED visit. It is known that patients upon ED discharge have a low rate of follow up with the pediatrician and the opportunity to initiate an appropriate long-term management may be missed.

The National Asthma Education and Prevention Program (NAEPP) advocates for prescribing inhaled corticosteroids (ICS) in the ED to improve asthma control, but ED providers have been reluctant to do so. In 2018, a quality improvement initiative in our ED improved ICS prescription rates from 2% to 77% by using an electronic alert system and financially incentivizing providers for prescribing ICS for recurrent asthma visits.

The objective of this study was to assess whether ICS prescription rates changed after the financial incentive ended.

Methods: This retrospective study examined patients aged 4–18 with at least two ED visits for asthma within 365 days and no recent ICS prescription. Exclusion factors were developmental delay, bronchopulmonary dysplasia, cystic fibrosis, sickle cell disease, and/or interstitial lung disease. This study included patients who presented to the ED from January 1, 2019 to December 31, 2019. Data collection consisted of demographics, insurance, provider type, prior ICS, whether ICS were prescribed, and reasons for not prescribing.

Demographics and clinical factors were summarized using count and percent for categorical variables, and mean and standard deviation (SD), or median and interquartile range for continuous measures. Factors were compared between those discharged with and without an ICS prescription, using the Fisher exact test. All statistical tests were 2-sided with significance at 5%.

Results: There were 96 eligible patients identified during the study period. ICS prescription rate without the incentive remained high at 0.74 (0.59, 0.86) and was not significantly different than the rate with the incentive of 0.77 (0.65, 0.87), with p value 0.82. No statistically significant differences were detected in baseline characteristics between patients discharged with and without an ICS prescription.

Conclusion: This study confirmed that an electronic alert advising ICS prescription in the ED for patients with recurrent asthma visits is effective, even without a financial incentive, which makes it highly sustainable. The strategy of using electronic alerts to remind providers to prescribe recommended controller medications for chronic diseases can further be implemented in other acute care settings and for other disease processes.