JURNAL ASTHMA - Factor Associated With Patient to the Emergency Department for Astgma Therapy

8/17/2019 JURNAL ASTHMA - Factor Associated With Patient to the Emergency Department for Astgma Therapy

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AL-Jahdali et al. BMC Pulnunoty Medkine 2O12, 12,ffi

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Pulmonary Medicine

Factors

associated

with

patient

visits

to the

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Q

Abdulllah

Alshimemerir and

Saleh Al-Muhsen3

Abstract

Background:

Acute

asthma

attack

remain

a

frequent

cause of

emergency

department

(ED)

visits and

hospital

admission. Many

frcron

encourage

pataents

to

seek asthma

treatment at the emergenry department

These factor

may

be

related

to the

patient

himself

or

to

a

health

system

that

hinders asthma

control.

The

aim

of this

study was

to

identi0/

the

main factors

that

lead

to the

frequent admission of

asthmatic

patients

to

the ED.

Methods:

A

cross-sectional survey

of

all

the

patients

who

visited

the emergenry room with

bronchial asthma

attack

over

a

9-month

period

was

undefiaken at two

major

academic hospitals. The followlng

data

were

collected:

demographic

data, asthma

control

in

the

preceding

month, where

and by

whom the

patients

were

treated,

whether

the

patient

received

education about asthma

or

its

medication and

the

patients'

reasons for visiting

the ED.

Result

Four

hundred

fifty

(N:450)

patients

were recruited,

39.1% of

whom

were males

with

a

mean

age of

423 t

16.7. The mean

duration

of

asthma was 155.901 127.13

week-

Approximately half

of the

patients

did

not

receive

any information about bronchial

asthma

as

a disease, and

40.7%

did

not receive

any education regarding

how to

use

asthma

medication. Asthma was

not

controlled or

partially

controlled

in

the

majority

(97.7%)

of

the

patients

preceding

the

admission

to

ED. The majority

of

the

patients

visited

the ED to

receive a

bronchodilator

by

nebuliser

{86.7%)

and

to obtain

oxygen

(75.1Va}-

Moreovet

20.996 of

the

patienls

believed

that the

ED managed

them

faster

than

the cliniq

and

21.1%

claimed

that their

symptoms

were

severe enough

that they

could

not

wait

for

a clinic visit.

No

education

about asthma and

uncontrolled

asthma are the

major factors leading

to frequent ED visits

(three

or

more

visits/year),

pvalue=0.0145

and

pvalue=0.0003,

respectlvely.

Asthma

control

also

exhibited

a

significant

relationship

with

inhaled

corticosteroid

16

use

(pvalue

=0.0401)

and education about asthma

(p-value

=0.0117).

Conclusion:

This study demonstrates

that

many avoidable risk factors lead

to

uncontrolled asthma and

ftequent

ED

visits.

Keywords:

Asthma,

Control,

Inhaled cortisone, Emergency

department

Background

Asthma

is a

common condition that

affects 5-10%

of

the

population.

The incidence and

prevalence

of asthma

have increased

during

i:he

past

20 years

[1,2J.

The

preva-

Ience

of brcnchial asthma among

Saudi

patients

is

ap-

proximately

20-25%

[2,3].

Poor

asthma control remains

a

frequent

cau$e

of

emergency

departmeat

(ED)

'

Conespondence [email protected]

lDepartment

of

Medicine,

fulnonary Divisior.f,O Kirg Saud

Unilerslty

for

Health

Sciences,

Riyadh, Saudi Arabia

tlead

of

Pulmonary

Divi$on,

Medical

Direcor of Sleep

Disorders Center,

Adjunct

professor

llccill

Unilerity,

King

Saud University for Heakh kbnces,

King

Abdulair

Medical

City,

Rifddh,

Erydh, Saudi Arabia

Full list

of author

infonnation is

anilable at the end of the article

presentation

and

hospital

admission

[a].

The

cost

of un-

controlled

asthma

care is

substantial.

For

example, the

utilisation

of the

emergency

department

for

asthma

management

accounts

for

almost

one-third

of

all

asthma

costs

in

the

United

States

[5].

There

are

many factors

that

lead

patients

to visit

the

ED.

The

most common reported factors include

as$ma

severity,

poor

compliance, the inappropriate

use

of inha-

Iers,

incorrect

perceptions

about

bronchial asthma

as

a

disease

or

about

its medication,

the cost of medication,

lack of an asthma action

plan,

comorbi&ties, over reli-

ance

on short

acting bronchodilators,

polludon

and

changes

in

the

weather,

the

patient's

level

of

education

and low socioeconomic stahrs

[5-19].

./- \

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20

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Reducing the use of the ED for

acute

asthma treat'

ment

remains a major

goal

of

asthma management

that

is

recommended

by

all

grridelines

[20-23].

It

is

not

clear

why many

patients

in our community still visit the ED

and

depends

on the

ED

as

their

primary

if

not

sole

source

of

care.

It

is irnportant to

understand tJre factors

associated

with

astlrma-related

ED visits in order to re-

duce

the

use

of ED resource

utilization

for asthma treat-

ment

There

are many

factors that

encourage

pa6e.nts

to

seek asthma

treaknent at the

ED

and

these

factors

may

be different

from

one

society to another. It is very im-

portant

to

identiff

characteristics

ofthe

patients

and de-

ficiencies in our health care delivery

system

related

factos causing

poor

asthma

contrcl and &requent visits

to the

emergency

department

(ED).

The

objective

of

this

study

is to

evaluate

the most imporhnt

factors

asso-

ciated

with the

increased usage

of

the emergency

depart-

ment

in

our population

Methods

This

was

a

cross-sectional

study conducted at the King

AMulaziz Medical City- King

Fahad National Guard

Hospial

in Riyadh

{KAMC-IGNGH)

and the King

Kha-

lid

University

Hospital

(IC(UH).

We enrolled

patients

with

diagnosis

of

asthma

who

visited

the ED

for

asthma

management between

August

2010

and March 2011,

The enrolled

patient

rnust

have a

documented

diagnosis

of bronchial

asthma

as

diagnosed

by their

primary

treat-

ing

phlrsician

and on

prescribed

inhaled

corticosteroid

(ICS)

for

at

least the last

three

months.

lifle

excluded

patients

with

undocumented diagnosis

of

bronchial

asthma and

not

on

ICS

as

per

their

medical

record.

This

study was

approved

by

the

IRBs

of both

hospitals

(Ref

IRBClf 23fil). During ED visit, the

traind co-

investigator

collected

information

about

demographic

data, the duration of

the illness, the mdication

used

for

asthma therapy

and if the

patient

received any for-

mal asthma education about asthma as a

disease,

how

to

use

their

inhaler

devices

and by

whom. The

patents

were asked about

regular visits to outpatient

clinics,

where they follou'ed up, and how many times they vis-

ited

the

emergency department

or

were

hospitalised

oner

the

last

year.

C,o-investigators

also

veri& this in-

formation

by

reviewing

the

medlcal record

of

each pa-

tient and

assess asthma

control

over

the last

month by

administering

validated published

Arabic version

af

Asthma

Control

Test

(ACT)

[24].

Statistical analysis

The

collected dah were transferred and analped

using

SAS@

version 9.2

(SAS

Institute Inc., Cary, NC). De-

scriptive statistics, such as

means,

shndard

deviations,

or median were

used

to

summarir.e age

and duration of

asthma

diseare.

Percenages were also used

to

summarize

Page

2

of

7

gender,

ICS use follow up with

clinics, education

level,

educated

about medication,

educated

about asthma, and

reasons

for visiting

the ED.

Mann-Whitney

test

was used

to

compare the di*tributions of

asthma

disease

duration

across number

of

asthma-related ED visits

(<

3 vs. > 3).

Chi

squared tests

were

used

to test

the

associations be-

tween

gmdeq,

ICS

use,

follow

up with clinics,

education

level, educated about

medication,

and educated about

asthma

across

asthma-related

ED visits. Similu

analysis

used for asthma control test

(ACT).

Multiple

logistic

models were used

to identi& the risk factors that

asso-

ciated

with

three

or

more

asthma'related

ED visits.

P-

rralues

less than 0.05 were considered sigrrificanl The

odds

ratios

(ORs)

with 95% As

were reported

to de-

scribe

the skength of

these associations.

Results

Four hundred

fffty

(n

=

450)

asthma patients

were

en-

rolled

in the studp Of the 450 asthma

patients,

176

(39.1%)

were

males a*d

274

(e.9%)

were females The

patientt

demographic and clinical characteristics

are

shown

in

Table

1. The mean

pa6ents'

age

was

42.3

116.7

years,

and

the

mean duration

of

asthma

illness

was

155.9O

*.127,13

weeks.

Two hundred

and

seventy

(60.0%)

patients

were

regularty

followed up with

a

phys-

ician,

urhile

180

(40.096)

patients

did not

have any

follow

up arrangement

after

their initial

diagnosis of asthma

Approximately half of the

patients

did not

have any

for-

rnal education about asthma 232

{Slfr%),

while

183

(40.7%)

did

not

receive

education

about

how

to

use

the

medication

or

the

devices.

Of

218 patients

received

in-

formation about

asthma as a disease,445% received

this

information ftorn

phpicians,

7.8%

received

the

informa-

tion

from

asthma educators, and

4.7% neceid

the

infor-

mation from

a

pharmacisL

One hundred sixty five of

the

450

patieats

(i63%)

vi$it€d

the

ED three or nore

per

year.

The

patients'asthma

control

for the

last

mondr

be-

fore the ED visit was

as

follows:

23,4%

af the

patients

with uncontrolled

asthma

(ACT

score

< L5),

74.4%

of

the

patients

with

partial

controlled asthma

(f6

< ACT

score <

23), 1.8%

of fie

patients

with

complete

con-

trolled asthma

(ACT

score

> 24), and 0.5%

of

the

patients

with

missing

ACT

score. When

the

patients

were

asked

about the

reason

for

the

ED

vi$it, the major-

ity of the

patients

86.7%

indicated that

receiving

a nebu-

lised

bronchodilator

was

the

maior reason

Three

hundred rhirfy-eight

(75.1%)

patients

mentioned

obtain-

ing oxygen as their reason, mhile

20.9%

believed that

the

ED

treated their asthma

fastex,

and

21.1%

daimed

that

their asthma was

severe

enough that they could

not wait to visit the clinic

(Table

2). The majority

of

the

patients,

74,7%,

did not know what triggered their

asthrna, and 81.6% stopped all asthma therapy

once

they

felt

better.


3/7

Gender

Education level

Employment

Status

Follow up consistently

with

doctor

Follovrup

clinic

No


fto

education

about

rYledication

(devices)

ED

visis

Asthma

control

AL-Jahdali

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Pulnwnary Mdkine 2Al2,

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W

Tabb I Patient demogr+hics and dinkal asthma

draracteristlcs

(t{

=

450}

Age,(tt@n 9)

Duration

of illnes

in

weeks (Mean

*

5D)

Page

3 of

7

32.9%,

p-value

=0.0003).

Table

4, shows

the relationships

ktween asthma

control

and

patient's

demographic and

clinical characteristics.

There

was

a relationship between

patient

believe

of

needing

orygen

for

asthma therapy

and three

or

more

ED

visits

(40.5%

versus

28.2%,

p-value

=0.S209),

there was no relationship beh,seen

vi$it

ED

primarily

to

obtain a bronchodilator and three

or

more

ED

visits

(36.5%

versus

43.3%,

p-nalue

=0.3081).

Mann-Whitney test

revealed there uras

no

relationship

between

the

duration

of

the disease and

the

number

of

ED

visit

(p

=

0.3944).

An

education

level higher

than

high

school

{p-value=0.0071),

an uncontrolled

asthma

(p-value

=

0.0063), and

irregular follow up

with

clinics

(p-value

=

0.0328)

were

highly

associated

with three or

more

asthma-related

ED visits,

after

being

controlled

for

gender,

ICS

use, ducation

level,

educati,on about

medication, and education

about

asthma

(Table

5). As

found

in

this

study,

the

patients

with

university

educa-

tion

were

twice

more

likely to visit

the

ED

than

the

patients

$'ith high

school

or

&ot

educated

(OR:

2.359;

95%

CL

1.263,

4.N7). The

patients

with

uncontrolled

asthma

were twice as

likely

to €ome to the

ED

compared

with the

patients

with

controlled

asthma

(OR:

1.924;

95%"A:

1203, 3,O7n This study also

showed

that

asthma

control

as

determined by

ACT

had a significant

relationship

with

ICS

use

(p-value

=

0.0401),

asthma edu-

cation

(praalue=0.0117),

ED visit

primarily

to obtain

a

bronchodilator

(p-value

=

0.0001), and ED visit

to

obtain

oqgen

(p-value

=

0"0203).

The distribution of

uncon-

trolled

asthma varied depending

on

patient

ICS use

Q7,6% irregular,

while

19.4%

regular

use). Those who

had

not been educated

about

asthma were

more

likely

to

have

uncontrolled

asthma

than

those

who

had

been

educated about asthma

(28.1%

versus 18.1%).

Dkcussion

While

this study is not

epidemiological,

it

is

the

first

study

to

investigate the factors leading

to

ED visits

in

a

sample

of

Sau& bronchial

asthma

population

and

the

characteristics

of

those

patients.

The major

strength

of

this study lies

in

direct

interviewing the

patients

and

confumation of the information obaiaed

by

reviewing

the

medical record- It is very

important to

examine these

factors,

because,

we observed

that

many

patients

depend

on

the

ED

for

asthma

management.

Ifuowing

these

fac-

tors

may

help

address some

of

the

deficiencies

in

our

health system. The national and international

guidelines

for

the management

of

bronchial asthma emphasise

pa-

tient

education and

rqular

follow up with

asthrna

pro-

fessional.

Our

study

generally

showed

that

a substantial

number of

patients

do

not

follow

up

asthma

Eranage-

ment

with

physicians

and

did

not

reeeive any education

about asthma as

a disease. A zubaantial number

of

our

patients

also used

ED as an

easy

way

to access

their

%

Fenale

,'/p

sd,rp,l

High

rchod

or

bs

University

Mising

Emf,oye

5rudent

llousewife

tlm

15) made three

or more ED visits

(52.4%

versus


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et aL BtiC tufuonary

Mdkine

2012,

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47

1

-2ffi/

1A8o

Table 2 &rowledge about asthma

managcment

and

Reasons for visi$ng the ED

(il

=45O1

R@aforA)*tt

Msit

ED

primarily

to

obtain a

bronchodilator

tbJ

Vlsit

EO to

obtain

orygen

75.1

The

sorerity of asthrna doent

allo

,

the

patient

to

wait for

a

2l.l

dinic

visit

Belief that the

patient

is

treated

faster in

the

ED

'lhe

ED is available

24

hours

a

day

The

patient

treated directly

without

delay

Medication

given

as

r€buliar

at ED

is more useful

tltplxd@oooutd,,,nnl,ntrr,ryrut

Take

bronchodilator torelieve

symptoms

only

Srop

|cs therapy when feel

better

Beliele

long term

use

of

inhaler

unsafe

Belisae

continues

use of

inhaler

cause deperdence

35.1

Believe asthma thenpy

use

is

effect overtirne

403

Does

not knoar what trigger

asthma

synptoms

74J

Does

no kpur wtut *orlld

do

duing

asthma attad

289

rN

manno{,erumMloolcdedlrtlat.

asthma

management

instead

of

keeping

a

follow up

ap-

pointrnent

with asthma

professionals.

Thi$ is

not

trnique

for

our

population,

and

many

studie

have reportod

the

same

findings

[14,f525].

The majority

of

our

padents

exhibited

uncontrolled

or

partially

coatrolled bronchial

asthma

t973%)

in

the months

preceding

the

ED

visii

which

is

unaccepably higtr.

However,

this

result

also

consistent

with our

previous

finding

of

a substantial

Page4o/.T

percentage

of

uacontrolled or

partially

controlled bron-

chial asthma

(95%)

among the

patients

in

major

tertiary

care

hospitals

[26].

The

result

of

our

study

raises na-

tional

concerns

regarding

our

current

asthma nranage-

mmt

system,

which

requires

better

health

delivery

struchrres, easy

dinic

access

for

ptients,

better

patient

education,

better disseminatior of the current

national

asthma

guidelines

and better monitoring.

Asthma educa-

tors only educated

17%

of

tlre

patients

in

this study;

&is

was

primarily

due

to the

lack

of

trained asthma educa-

tors

in

many tertiary care

hospitals and definitely

contri-

butes to

the

number of

patients

with

uncontrolled

asthma

and the number

of

ED visits. The maiority of

our

patients

who

had

follow

up

visits

(40%)

attended

the

follow up

at

a

primary

care clinic,

where the

setting

for

asthma education

is

not

very strong.

The

lack of

patients


is

obvious, as almost

4d)96

of

our

patients were never

taught how

to

use

asthma

devices.

Studies

have

shown

that ensrring that

asthma

patients

undersand their

medication and the appropriate use

of

a drug delivery

device

contributes significantly

to asthma

control

ln40l.

Furthermore,

Hanania

NA

et

aL

[31]

have

shown

that

many

of

the medical respon-

sible

for

instructing and

educating

patients

in optimal

inhaler

use

lack rudimentary skills

with

these devices,

seldom receive

formal

training

in

the

qse

of

inhalation

devices, and

rnay

be

not familiar with

newer inhalation

devices and

techniques.

We believe

that

our

study iden-

tify

probably

a

eubstantial

problem

in

our tealth care

system,

particularly

in the

primary

care setting.

Abudah-

ish,

A

et

al.

t32l

have

shown

that

asthma

management

in

primary

care

is unsatishctory.

Our

study also

revealed

20.9

19.1

20.9

r9.6

873

8r.6

427

Table 3 The assodation beturcen asdrma-trhited

ED

vtslti

and

demographk and

dlnlal

characterisffcs

{ll

=

44t}

Vqffi

< 3 viCts

>

3 vlshs

(n=276)

(n=l6|il

?

rd€

Crender

Regular lCS use

Follor

up with

clinics

Education

le\el

Educated about medication

Educated about asthma

ACT

%

tiale

Fanok

Ya

,vo

Y6

lvo

HiTh

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tiolty/Fuil

controlld

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6ra

65.6

596

61.4

ils

&a

4.4

645

60.r

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573

476

67.1

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352

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355

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Page 5 of 7

Table

t[

The

assodafon between ttre astbna

cont]ol t€st

{lCT)

and

denrognphk

and

clinlcal draracurisdcs

(N=4t8}

Lantt

P.rd.lly/full

controlled

(n

=

343)

t{ot

conmlled

(n

=

t(lti)

ttd.n

Gender

Regular

|CS

use

Follow

up

with

clinics

Education

level

Educated about medication

Educated aboutasthma

Yes

IVo

%tt|r,b

Fqnab

Y6

iio

Yes

No

High

xtrool or

les

Univeryity

Y6

,vo

760

765

80.6

72.4

n8

75.1

n2

72.1

785

744

8r.9

71.9

240

23.1

19.4

27.6

222

24.9

228

279

21.4

26.0

l8.t

2&l

04220

0.0401*

05188

038s3

02650

0.01 lr

T,|p(,,4{4d/d/re

statisdrbsignlfunt otrtre

$5levdtff ,f,r', tqe

rwtd

/od/v

daintol.

the

common

misundersianding

of

using

the ED

to

re-

ceive

a

nebulised

bronchodilator

and oxygen as

primary

therapy

for

acute asthma among

many

of our

patimts.

Approximately

803i

of

the

patients

were

classified

widr

mild

asthma by the National Asthma

Educating Program

(NAEAP),

and tlrese

patients

would probably

obtain

re-

lief

from

their

symptoms

by

usrng rescue

MDI

broncho-

dilator without

need

to

visit ED if

they received

the

appropriate

education.

rife

also

exarnined the factors

that

lead

to

three

or

more ED visits

over the

preceding

year,

believing

that

patients

with

frequent

ED visits

probably

have less

control over

their

asthma. In

our

study,

the

more

educated

patients reported

three

or

more

ED

visits;

however,

the

nurnber

of

these

patients

was generally

small

(13%),

and

most

of

them

experi-

enced moderat€

to severe

asthma

(data

not

shown).

Similar

to

ofher

strdies investigating

the

lack

of

asthma

education,

uncontrolled

or

pa*ially

controlled

asttuna

were

major

r€asons

for the

ED

visit, in addition

to in-

consistent

clinic visits

[15,16].

This

study

is

only

based

on

two

teaching hospitals

in

the

central region

of

Saudi

Arabia and may

not

reflect the situation

at the national

level. However,

we

believe

that

this study reflects

the

current

general

characteristics

and

risk factors

for

crisis

oriented care

and dependence on

the

ED

for the

man-

agement of bronchial asthma

exacerbations Further-

rncre, the situation

rnay

be

even wo(se if

we

assessed

these

data at

the

country

level, where

the infrastrucErre

for

asthma

management may be less well

Limitations

One

of the

major

limita[ons

of this study is the

inability

to assess

the

components

or

Sualrty

of the

different

asthma

education

or

iaformation

prqtrrms

our

asth-

matic

patients

received

from health

care

professionals,

In

addition, we

did

not

examine

the detailed risk factors

for

astlma

exace6ation,

sueh as an environmental

risk

for exacerhtions

at

home

or

in

working environments.

The

second

limitation

is

the lack

of

an

economic eyalu-

ation

for

an ED

visil

While

the

Saudi Arabian

govem-

ment

provides

free health care

for

all

Saudi citizens, we

could not readily

assess

the

accessibility

of

outpatimt

Table

5 lhe

oddi

ratbs

md

9t96 Cls for

tte

rtsk factors

assochted

rridr

tirce

or

rnore

as0rma-rehted

E rdsits

ofi

gli%cl

lntercept

Age

Gerder

Regular

ICS

use

ACT

Follow

up

with

clinics

Eduotion

lercl

Eduoted about medication

Educated

about asthma

Female

No

Uncontrolled

No

Univeaity

No

No

424a7

0.00344

0.0694

0.0594

03272

427{6

0.4292

0.0790

02u2

03s2

05984

05r92

06348

0.0063*

0.0328r

0.0071*

05844

0.1506

r.003

1.149

1.126

1924

o5n

2359

1.171

1504

0991

0.753

0.690

1"203

0349

1263

0665

0862

1016

1152

ta38

3077

0.956

4.47

2M2

252s

'WaA

Ch*r$nE

tuffi

b

ttgntficiltt

ot d7€.$ led.;


6/7

AL-Jahdali

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http:/rtww.biomedcentral.com/1471

-24€6,1

1

A8

clinics

at both

institutions,

as it was not

the aim of

the

study.

Another limitatioa

is

not

comparing &e

risk

fac-

tors

of our

patients

to thoe

patients

who

attend

out-

patient

clinics; howevef,,

our

prwious

study

found

that

the

majority of the

patients

at

outpatient clinics

stjll

have

uncontolled

asthma

[26]

and hold many

false belie8

and misconceptions

about bronchial asthma as a

disase

and the role of

inhaled

corticosteroids

and the frctors

affecting compliance among adult asthmatic

patimts

[33]"

Conclusion

Our

study

has identiffed

serreral factors that increase rhe

risk of

repeated ED

visits

for the

crisis

oriented

care

of

asthma.

The major

factors

we

identified

are a lack

of

asthma education, the lack of regular follow

up

with

spe-

cialised asthma clinics,

patient

misunderstandings

about

the role of

EDs in

the

treatment of bronchial

asthma,

and

the

underutilisation

of

inhaled steroid

use.

Most

of

these factors can

be addresed by

heal*r

care

providers,

and health

ere

planners

can recti&

these

problems

by

restructuring

asthma management

resources to empha-

sise

a

rnore multidisciplinary

approach

and invest

in

training

additional

asthma educators

to

participate

in

pa-

tient

education

and

instruction

of

how

to

use

inhaler

devices and asthma action

plans.

Compedng lnt€rertj

The authors

declar€ that

they have

no competing interests.

Atrthor{ contributons

JH:

Rs/iew

the

scientific literature pertinent

to the

research question.

W.iting

the

proposal

and

responding

to rev'ewer

and

IRB

comments.

Caeate

data

collection form arxj

draft the

first

manuscript

AA:

perform

all statistical

analysis and

writ

the

resuh

section. HA: Supewising

the data collection

at

KAMC.

SB:-Scientifically contribute to writing the

proposal.

HR Supervising

the

data collection at

KKUH. SA

: Providing

scientific expertise and

operational

guidance

to

data coilection at f'Ai1C and

actively

gecipitaring

in

contdbuting

in

tt€

manuscript

writing

as

per

assignment by

Pl.

M5:

ScientifiGlly contribute to writing the

proposal

and study conduc

at

KKUH.

All

authors read and approved the final manuscript.

Adooude&mentt

We

would

like to thank

Dr.

Ali Al{arhan

and Dr.

Raeied

Hejaze for facil;tating

our access to the

EDs

and

helping identiry

potential

patients.

We also thank

King Abdullah lntemational

Medical Research

Center

((AIMRO

for funding

and

provide

editing supponing

this

research.

Author

details

rDepartment

of

Medicine,

Pulrnonary DMsion-lCU,

rcrg saud

University for

Health

kierres,

Rrydh,Saud Aobia

lDeprtntent

cf Epidemiology

ard

Biosutistics,

College of

Publ'r

Health

and

l-hahh,

lnformatict

Xing

Saud bin

AMulaziz

University for

Health kiencet R}adh,

Saudi Anbia.3Asthma

Research

Chair and

Prince

Naif

Center for

lmmunology

Research,

Depatment

of

PaedUuis, C;ollege

of illedicirc, Kqg

Saud Unirrcrsity, Ripdh.

Saudi tuab&L

lHead

of

Pulmonary

Divisiorr lvledical

Direcror of

Sleep

Dsorders

Center,

AdJunct

professor

Mcclll

Un[rerslty,

XlrE

Saud

Unlver*y

for

Health Science$

King

AMulaziz

Medical

City,

Ripdh,

Riyadh, Saudi

Arabia.

Received

27

No\rember

2012 A€(epted:

14 De€ember

mI2

Published:

17 Decembs 2012

Page

6 of 7

Reiercnces

1.

Gupta

R5, Weiss KB:

The

2d07 national

asthma

education and

preventioa

pmgram

asthma

guidelines

accelerating their implanerUtion

ard

facilitating

thef

impact

on drildren with

asthma.

Pedrr*cr

?89,

t23(Supd

3):S193-Sls.

2 Al

Frayh

A&

Shakoor

Z

Gad

El Rab MO, Hasnain

SM:

lncreased

premlence of asthma in

sandi arabia.

in

n Allergy Asthma lmmunol

2001

,

w31292-296.

3. Al

Fray*r

A& Al llahdi

M,

Sener

A8,

la$edi TQ Epidemiofogy

ot ertkna

and

allergic

ftinitis in

trw coasbl regions of

Saudi

Aralia

Allug

lnmunol

tPori$

1989,

2100)389-393-

4.

Adams R, Smith

8J,

RuSn

ftE:

Factors

associat€d

with tspital

dnissions

and

repeat

emergen.y deparfi€fit virits

for

adults uridl

as*rma.

fhara(2CfF,,55(n56-573.

5. Weiss

K8,

Gergen P.|, Hodgson

TA

An

eco{rofliic evaluation of artfima in

the

Unied

Sates.

N

Wt

j

EM

1W2,32d13I862-866"

6

Abisheganaden

J,

Sin

Fai

tam

KN,

Lim TK A

pofih

d

acute

as*rm

patienB p.esenSng

to

dre

emergenct

rap/:a.

Singapoft

Med

J

l%,

37(3)252-254.

7. Aelony

t

tiYhy

patients

wilfi ast'tma

go

to the ern€rgency room.

lni{n

1S0,243{8):732

8. Al

Zabdl H,

E

Sharif

N:

Factss

assochted with ftequsrt

emergeno/

room

attendance

by asthma

patients

in Palesllne.lnt

jTufutc

LutE D:ts

2c07,1U8192A427.

9.

Berkas BM, Bkcan

A:

Effecs

of

atrnospheric

stdphw

diodde

and

particulate

matter concentrations

on eme,g€ncy

rcorn admisiom due

to asthma in Ankan.

Tufurk Torok

2A03,

5l(3)131-238.

10

Chugh K Acute

asthma

in

emergency

room. lndian

J

Pediotr

2fi3,

Tqsupd l):9&S33.

I l.

Dalcin

PT,

Piovesan

DM,

K,ang

t

Femandes

AK, Franciscatto

E,

Millan

I

ei ,I

FactoB

assoaiated with

emergency departmert

yisits

dlE to a€ute

asthma. Braz

J

lkd

&nl

Res

2W,37(9)1331-1338.

12

Dales

RE,

khlreiuer

I

Ken

P,

Gougeon

L

RMngton

R

Draper

J:

Hsk faGors

fu

recunent

emergrenqy department

visis

for a$hrra liora( lgg5,

5q5)520-524.

13.

Ford

JG.

lvlqnr

lH,

Stemfels

P,

Findley

5E,

Itldean

DE, Fagan

j(

a ol

Pattems

and

predictors

of asfima-relatd

emergency departrnent

use

in

tlarlern.

Gresr ?001. 120(4):1 1

29-l

1 35.

14.

Garrett

Jf,

Mulder

J,

WongToi

H:

Chancreristics of a:*rmatics using an

urban

accidem and emergency departmer& NZrtedl 191]8.

l0r(847

ft

11359-36r.

15.

Flanania

NA,

David-l$/ang

A, Kesten

S,

ChapEnan

XR:

Factors

arsociated

with

emergency depatment

dependence d

patients

with

asthma

Chett

I $L I

I

{2)290-29t

'l

6.

Lee

PY Xhoo

EM: Hor

well uere

asthmatic

patien8

educated abort their

asthma?

A

rtu*

a

the enrergency

depafinenl"-

Asia Pdc

J

Public ltealth

2e4. 16il)*5-49.

I

7.

Rodriguez-Maninez

CE, Sossa MP, GsreRodriguez

JA Factors

associated

to

recunent visits

to the

emergency departnent

for

asthma

exacerbatims in children: implications

for a health

education

programme.

Nlefgol tmmunapotlwl

(Madr)

affiF,

36{2):72-78.

I

8. Rossi

w, mnnula Vl. Huhti

E EmergEncy roo.n visitr for

acute attack

of

astlrma:

charactedzation d

patimts

and

visits.

fresdtotion

lW1,

58(1)21-2s.

19. Zeiga

ffS,

Heller

t

l,ldlon Mll, Wald

.J,

Fafloff R,

scfuiz

M:

fadtared

refend to

asthrna specialist reduces

relapees in asthma erneigency

room

visits.

JAIIe.gy Ain

kr,munol 191,87(6):1

160-1

168.

20.

National

Asthma

Education and Prevention

Program:

Expen

pnel

repo* I

guidefuesfat

tlr drrgnotis

end

mawgenent

af

asth*no-

Mefu

1MDL

nadanal heart

h$9. and

bbad

intttf.ne.

NIH

PuHicatlon No.

07-.4051. NIH

Publication No

07-,1051. 2007,

http//wwwnhlbi.nih.gov&uideliney'asrhma/

asthgdln.pdf.

Accesr

dare

02-12-2012.

21" Al-lr/oamary

MS, AHla,iF.i

MS,ldrees MM,

Zeiouni

lriX3,

Alaneri MO

Aljahdali

HH, er

ol

lhe

Saudi lnitiative fior asthma. Ann'llwx l,l&

W,

4{4)2r6-233-

22.

Bateman

ED, Hurd

SS,

Barrcs

PJ,

Bousquet

J, Drazen JM,

FitzGerald

M,

er

6t

Gl&al

stratqy

for

asfihma

rnanagement

and

Fe\rention:

GINA

executi\€

$mmary.

Eur Respit

i.2m8, 3l(1H43-78.

23.

Oancy i(

British

guidelines

on the managernent of

rthrna.

Tl]6td

2trp.,

5qli31-82.


7/7

24.

25.

26.

?8.

79.

Al-Jahdali er oL ilnC tuhtwnry trdicine 2Q12, l2fo

http:1r1*ww.biomedcentral.com/1

47 t

-2ffi

I

A

W

Lababidi

H, Hijaoui A, Zarzour M: Validaton

dtte

Anbi.

rrersion

dthe

asthma

ccnfol test

Ann

Ttpru Md

2ffi,3121:4447.

Malraeaux

FJ,

Houlihan D, Diamord Eti

Chawteri$cs

of astfima momlny

and

mortridity

in

Atican'tunedcans.

)

Asthma

1993,

3q6):431-437.

AFJahdali HH, Al-Hajjaj

t

5,

Alared ilIO,

Ze{toni

il,10,

AlTasan TH:

Astrma

contrd assessment

using asthma

corrd

test

amotrg

patients

attending

5

tertiary

care hospitals

in Satdi

Anbh.

Saudr

tkd

j2fffi,29l5l:714-717.

Pinto Pereira

t[4

Ctearcnt

Y.

h Si]va C ( [&lntosh

D, 9nrebn DT:

Undemanding ard use of hhaler

medkation

by astbmatics

in

specidty

care

in Trinidad:

a study

folhiliqg det

Elopment of

Cadbbean

guidelines

for

asdrma

manqerrent and

prevention.

Chest 262,

t2I(6):1833-1840.

Meyeye O0,&addo B& Undersandirlg

rdicatidr

ard

ttseof

drug

deliwy

device by asftmatic in tagos.

W85,t

Nr

I

lM 2c[E,27(3):155-159.

Pinto Pereira [-

Clernent

Y, Simeon

D

Educauonal

inten

enddr

for conect

pressurised

metered

dose

inhaler

tedrnlque in

Trinidadian

padents

*ith

asthma.

Pa&nr EdE

Couns

2001,420)3147.

Iurkas

H, Mungan D,

UFaI

Md

O$.Edgen

K

DeterdnanB

dasthma

cont

d

in

tertiary

hvel

in

Tur&ey:

a

oosssectiond

multieenter

survey.

J

,{stfima 201 0, 476)557-562.

Hanania

NA" Wnpan R,

Kesten

9

Chapman KR Medical

personnelS

luu*ledge ef and

$&yo

use

ddirry

devices.

ftktere*dose

inhderl

spacing

dla

ibers,

and

beatFacruaed

dry

powde

inhalers.

Ch€$

1994,

r05(1)r

r

1-r

16.

Abudahish

A, Bella

H:

Pdmary care

ph)rlciam

perceptions and p-act'rc6

on

as*nna

care in Aseer

E{rion

Saudl

rsfu-foudi

IM ]M,

27(3)333-337.

Al-JaMali

lltl, Ala}t.ani

lil,

AlOtaih

Sl. Hassao lt Alit'toamary M5,

Al-Duhaim 45,

et

at

Pe{cep'don

ofthe

roh

of

inhaled

cofticosteroids

and

factors

affecting

conpliance amoog

asdrmatic adult

patients.

56udi

nrd

l?f07.?5141,%9-573.

doil

0.1

1 86fl 47r

-246612{0

Clte

thls ardde

asr Al-Jahdali et a

Fxtors

assodated

wlth

pathnt

visits

to the

€nsgen depaiBne*

for

adlnE tlwapy- & fC fulrnorry

itedicine

2A1212ffi.

?aEe7

d7

Submityour next manuscriptto

BloMed

Central

and

take

full

advantage

oft

.

Convenlent

online

s{bmission

.

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p€er

review

.

I{o

space

(onstraintr

or aolor

figure

charges

.

lmmedaate

publkation

on

ac(€pta(e

.lnclusion

in

PubMed. {AS,

*opu' and Google Scholar

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JURNAL ASTHMA - Factor Associated With Patient to the Emergency Department for Astgma Therapy