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Clinical Investigations: ASTHMA |

Prospective Multicenter Study of Relapse Following Treatment for Acute Asthma Among Adults Presenting to the Emergency Department* FREE TO VIEW

Charles L. Emerman, MD; Prescott G. Woodruff, MD; Rita K. Cydulka, MD; Michael A. Gibbs, MD; Charles V. Pollack, Jr., MD; Carlos A. Camargo, Jr., MD, DrPH, FCCP; on behalf of the MARC Investigators
Author and Funding Information

*From the Department of Emergency Medicine (Drs. Emerman and Cydulka), MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Department of Emergency Medicine (Drs. Woodruff and Camargo), Massachusetts General Hospital, and Channing Laboratory (Drs. Woodruff and Camargo), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine (Dr. Gibbs), Carolinas Medical Center, Charlotte, NC; and Department of Emergency Medicine (Dr. Pollack), Maricopa Medical Center, Phoenix, AZ.

*From the Department of Emergency Medicine (Drs. Emerman and Cydulka), MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Department of Emergency Medicine (Drs. Woodruff and Camargo), Massachusetts General Hospital, and Channing Laboratory (Drs. Woodruff and Camargo), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine (Dr. Gibbs), Carolinas Medical Center, Charlotte, NC; and Department of Emergency Medicine (Dr. Pollack), Maricopa Medical Center, Phoenix, AZ.


*From the Department of Emergency Medicine (Drs. Emerman and Cydulka), MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Department of Emergency Medicine (Drs. Woodruff and Camargo), Massachusetts General Hospital, and Channing Laboratory (Drs. Woodruff and Camargo), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine (Dr. Gibbs), Carolinas Medical Center, Charlotte, NC; and Department of Emergency Medicine (Dr. Pollack), Maricopa Medical Center, Phoenix, AZ.


Chest. 1999;115(4):919-927. doi:10.1378/chest.115.4.919
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Study objective: To identify factors associated with relapse following treatment for acute asthma among adults presenting to the emergency department (ED).

Design: Prospective inception cohort study performed during October 1996 to December 1996 and April 1997 to June 1997, as part of the Multicenter Asthma Research Collaboration.

Setting: Thirty-six EDs in 18 states.

Patients: ED patients, aged 18 to 54 years, with physician diagnosis of acute asthma. For the present analysis, we restricted the cohort to patients sent home from the ED (n = 971), then further excluded patients with comorbid respiratory conditions (n = 32). This left 939 eligible subjects to have follow-up data.

Interventions: None.

Measurements and results: Two weeks after being sent home from the ED, patients were contacted by telephone. A relapse was defined as an urgent or unscheduled visit to any physician for worsening asthma symptoms during the 14-day follow-up period. Complete follow-up data were available for 641 patients, of whom 17% reported relapse (95% confidence interval, 14 to 20). There was no significant difference in peak expiratory flow rate (PEFR) between patients who suffered relapse and those who did not. In a multivariate logistic regression analysis (controlling for age, gender, race, and primary care provider status), patients who suffered relapse were more likely to have a history of numerous ED (odds ratio [OD] 1.3 per 5 visits) and urgent clinic visits (OR 1.4 per 5 visits) for asthma in the past year, use a home nebulizer (OR 2.2), report multiple triggers of their asthma (OR 1.1 per trigger), and report a longer duration of symptoms (OR 2.5 for 1 to 7 days).

Conclusion: Among patients sent home from the ED following acute asthma therapy, 17% will have a relapse and PEFR does not predict who will develop this outcome. By contrast, several historical features were associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinician may wish to consider these historical factors when making ED decisions.

Abbreviations: CI = confidence interval; ED = emergency department; IQR = interquartile range; MARC = Multicenter Asthma Research Collaboration; OR = odds ratio; PEFR = peak expiratory flow rate

Figures in this Article

Acute asthma relapse following treatment and discharge from the emergency department (ED) remains a substantial problem. Previous studies have established that recovery from acute asthma occurs slowly, requiring around 7 days in many patients.1,,2,,3 Asthmatics with poor clinical response following 4 h of ED treatment are likely to experience even slower recovery.1,,4 Recent studies indicate that failure to respond promptly to initial treatment may characterize slow responders.5,,6 Various authors have found relapse rates from 11% over the course of 3 days, up to 30% over several weeks.7,,8,,9,,10 Potential risk factors for relapse include peak expiratory flow rate (PEFR) in the ED10,,11 and a variety of historical factors,12 such as number of ED visits for asthma in the past year. All of these studies, however, have been performed on small patient populations at single sites and their results may not be generalizable.

The purpose of this prospective multicenter study was to determine factors associated with acute asthma relapse among patients being sent home from the ED. The utility of finding such factors would be to guide ED management of acute asthma. Patients found to be at high risk might be the target of more intensive outpatient management. Such high-intensity programs have been found to be effective in limiting ED visits for asthma.13,,14,,15,,16

Subjects

This study combines data from two prospective cohort studies performed during October 1996 to December 1996 and April 1997 to June 1997, respectively, as part of the Multicenter Asthma Research Collaboration (MARC).17 This study was designed prospectively to evaluate a number of aspects of ED asthma care, including relapse. Using a standardized protocol, investigators at 36 EDs in 18 states provided 24 h/d coverage for a median of 2 weeks and enrolled 1,281 patients with acute asthma. All patients were treated at the discretion of the treating physician. Inclusion criteria were physician diagnosis of acute asthma, age 18 to 54 years, and ability to give informed consent. We relied on the physician’s diagnosis of asthma as no set criteria were used to verify the diagnosis. Patients were specifically asked the age at which they were first diagnosed as having asthma. Repeat visits by individual subjects were excluded. The study was approved by the Institutional Review Board at each of the 36 participating hospitals.

The present analysis is restricted to subjects who were sent home from the ED (n = 971). We further excluded subjects who were noted to have concomitant COPD (n = 17), pneumonia (n = 10), or congestive heart failure (n = 5), leaving 939 subjects. Of these, 641 (68%) underwent the 2-week telephone interview and have relapse data.

Data Collection

The ED interview assessed patients’ demographic characteristics, asthma history, and details of the current asthma exacerbation. Data on ED management and disposition were obtained by chart review. Follow-up data were collected by telephone 2 weeks later using a structured interview and included details of any urgent asthma visits, including changes in medical management. A relapse was defined as any urgent medical treatment for asthma, regardless of location of care. Patients were specifically asked if they had a worsening of asthma that led them to seek urgent medical care. All forms were reviewed by site investigators before submission to the Data Coordinating Center in Boston, where they underwent further review by trained personnel and then double data entry.

PEFR is expressed as percentage of a patient’s predicted value, based on age, gender, and height.18 Changes in PEFR are expressed as the absolute change in percent predicted (ie, final PEFR as percent predicted minus initial PEFR as percent predicted). Asthma-related ED visits and urgent clinic visits over the past year were treated as continuous variables. A high percentage of subjects had no hospital admissions for asthma over the past year (74%) and this was therefore treated as a dichotomous variable. Triggers of the patient’s asthma, in general, were assessed using a standardized list of potential triggers: respiratory tract infections, environmental allergens, other environmental factors, tobacco, exercise, ingested substances, reproductive, psychosocial, and other factors. The individual triggers as well as total number reported (range, 0 to 9) were recorded. Relapse was defined as any urgent or unscheduled visit to any physician (ED or clinic) for worsening asthma symptoms during the 2-week follow-up period.

Statistical Analysis

All analyses were performed using software (STATA 5.0; StataCorp; College Station, TX). Data are summarized using proportions, mean ± SD, and median with interquartile range (IQR). Univariate analyses of the relation of various factors to risk for relapse employed χ2 test, Student’s t test, and Wilcoxon rank sum test where appropriate. Variables that were associated with relapse at a two-tailed p < 0.1 in univariate analysis were evaluated for inclusion in a multivariate logistic regression model. This model was built with both forward and backward steps but was not done using the stepwise software function. Initially, variables were grouped into categories and assessed for colinearity by Spearman correlation and simultaneous inclusion in logistic regression models. Variables that were independently associated with relapse in these initial models were included in the model building process. When groups of similar variables showed significant colinearity, with no single variable attaining statistical significance in the initial logistic regression model, a representative variable from each group that showed the strongest association with relapse was chosen for inclusion in the model building process. The final model included all independently associated variables as well as age, gender, and race, which were chosen for their clinical significance. The possibility of a period effect was examined by adjusting for period of enrollment, but this did not materially affect any of the results that follow (data not shown). The multivariate logistic regression model yielded an odds ratio (OR) and 95% confidence interval (CI) for each factor in the model. All p values are two sided, with p < 0.05 considered statistically significant.

During the study period, 1,301 patients were discharged from the ED with a diagnosis of asthma; 939 of these patients were evaluated for the study. The patients who were not enrolled did not differ from the study population by either age or gender. A total of 641 patients sent home from the ED had complete follow-up data. These patients, compared with those not contacted by telephone (n = 297), did not differ significantly according to age, asthma medications used in past 4 weeks, number of asthma triggers reported, duration of symptoms for index flare, initial PEFR or oxygen saturation, change in PEFR during ED visit, percentage discharged on a regimen of systemic steroids, or health-care utilization in the past year for acute asthma (all p > 0.05). Contacted patients, however, were more likely to be female (69% vs 54%), white (25% vs 14%), never smokers (47% vs 36%), with private insurance (37% vs 21%), and a primary care provider (68% vs 46%); they were less likely to use the ED as their usual source of care for asthma problems (72% vs 83%; all p < 0.01). Among contacted patients, these factors did not predict relapse.

Among the 641 study patients, 17% (95% CI, 14 to 20) reported acute asthma relapse within 14 days of their original ED visit. Relapse events occurred over the entire follow-up period, with 37% of relapse events happening within 3 days, and 54% happening within 6 days of the ED visit. The average age of the cohort was 34 ± 10 years, and 69% were female. Twenty-five percent of patients classified themselves as white, 49% as black, 24% as Hispanic, and 2% as belonging to another race/ethnic group. Thirty percent of patients were current smokers. Thirteen percent of patients had been intubated previously. Seventy-four percent of patients had some type of medical insurance, and 68% had a primary care provider. With the exception of age and primary care provider status, these variables did not vary between those who suffered a relapse and those who did not (Table 1).

Over the 4 weeks before ED presentation, 85% of patients were using a short-acting inhaled β-agonist, 41% were using steroid inhalers, 22% had taken oral or parenteral steroids, and 31% were taking other asthma medications, including theophylline and inhaled ipratroprium. Approximately 6% of patients were using salmeterol. On univariate analysis, subjects who had relapses were more likely to be receiving inhaled short-acting β-agonists, inhaled corticosteroids, systemic corticosteroids, and other asthma medications (Table 1).

On arrival in the ED, the patients’ average oxygen saturation on room air was 97 ± 3%. Patients had an initial PEFR of 52 ± 21% of predicted normal, and were treated in the ED for a median of 2.9 h (IQR, 2.1 to 3.9 h). The final recorded PEFR was 80 ± 23% of predicted normal, with the final PEFR values obtained at a median of 2.2 h after triage (IQR, 1.5 to 3.1 h). The initial and final PEFR did not differ between those patients who suffered a relapse and those who did not (Table 2). Similarly, there was no difference in the improvement in PEFR during ED treatment between the two groups.

There also was no difference in ED treatment between the two groups (Table 1). Overall, 63% of patients were discharged from the ED on a regimen of systemic steroids, and there was no difference in discharge steroid treatment between those who suffered relapse and those who did not. The median prednisone dose was 40 mg (IQR, 40 to 50 mg) while the median duration was 5 days (IQR, 5 to 7 days). All but one patient received steroids for a duration that met or exceeded the National Asthma Education and Prevention Program guidelines (3 to 10 days). By contrast, a history of hospital admission for asthma over the past year, the number of ED visits for asthma over the past year, and the number of urgent clinic visits for asthma over the past year all were associated with relapse on univariate analysis (Table 1). For both ED visits (Fig 1) and urgent clinic visits (Fig 2), the increase in risk began with more than five visits per year. The risk of relapse increased approximately 40% for every five ED visits and approximately 50% for every five clinic visits. The univariate unadjusted data are provided in Table 3.

The results of the multivariate analysis are presented in Table 4. While adjusting for age, gender, race, and primary care provider status, both the number of ED visits for asthma over the past year and the number of urgent clinic visits for asthma over the past year were independently associated with relapse. History of hospital admission for asthma over the past year also predicted relapse; however, this variable was colinear with the number of ED visits and, therefore, was excluded from model building. Home nebulizer use was associated with a more than twofold increase in risk for relapse. Each asthma trigger reported by the subject increased the risk of relapse by approximately 10%. Patients with symptoms for > 24 h but < 7 days also were at higher risk of relapse.

This study confirms previous findings that a substantial proportion of patients treated in the ED suffer a relapse within days to weeks after ED discharge. Although there is no common definition of an “acceptable” relapse rate, 17% certainly represents a high failure rate. In this study, we have confirmed that easily ascertainable historical features define patients at highest risk. Since the National Asthma Education and Prevention Program guidelines allow for physician discretion in the disposition of patients with moderate airflow limitation after treatment, these higher-risk patients may be appropriate for inpatient or observation unit care.19 Patients with a number of recent ED or urgent clinic visits, multiple asthma triggers, longer duration of symptoms, or already using home nebulizers may be appropriate for admission, observation unit care, or close outpatient follow-up. There is not a consistent increase in risk of relapse as the number of asthma triggers increases (Table 3), suggesting the lack of a linear dose response relationship. We cannot, however, quantify the exposure to each of these triggers so that it is difficult to make such a conclusion. Further, patients with symptoms for > 7 days have a lower risk of relapse, suggesting that patients with chronic symptoms respond differently following acute therapy. Possibly the chronic nature of their symptoms makes them less likely to return for acute care.

Recent evidence indicates that ED visits can be reduced by educational intervention.20 Over the longer term, some clinicians have found that intensive management programs may prevent ED visits for acute asthma. Irwin et al15 developed a systematic management protocol based in a pulmonary outpatient clinic. Patients underwent intensive investigation to validate the diagnosis of asthma and also were evaluated for gastroesophageal reflux disease.15Patients had medication adjustments, including initiation of treatment with inhaled steroids, appropriate use of inhaled β-agonists, and consideration of the use of other anti-inflammatory medications. Using this comprehensive management scheme, the authors report that they were able to control“ difficult” asthma 74% of the time. Similarly, Mayo et al16 found that a focused management program with easy access to medical providers and medication adjustments significantly decreased asthma hospitalizations. It has not been demonstrated conclusively that an intensive ED-based asthma management program similar to these two models could prevent relapse following acute asthma treatment in the ED, but such programs seem worthy of further investigation.

A number of investigators have attempted to identify factors that place patients at high risk for relapse following treatment for acute asthma. This identification is important in light of the above studies, indicating that intensive management programs can reduce ED visits. Further, a recent study demonstrated that a peak flow-based action plan can significantly reduce subsequent ED visits over the course of 6 months.20Some authors have attempted to combine clinical criteria to identify patients at increased risk for a composite end point of hospital admission or acute asthma relapse. Fischl and colleagues21developed such an index using a number of clinical factors, including weight, wheezing, heart rate, respiratory rate, and PEFR. Two subsequent studies, however, were unable to validate the use of this post hoc scoring system.22,,23 More recently, a preliminary study of 54 patients found that patients with an elevated blood eosinophil count may be more likely to suffer relapse.24 Use of biomarkers to predict relapse remains an interesting but unproven approach to this challenging clinical problem.

Most attention to date has focused on the role of pulmonary function testing to predict relapse. Approximately 20 years ago, several studies showed that pulmonary function testing can identify patients who will require hospital admission following treatment for acute asthma.7,,25,,26 Around this same time, Kelsen et al10 found that patients who suffered relapses after leaving the ED were characterized by lower pulmonary function at discharge and a significantly lower percentage improvement in pulmonary function with treatment. Nowak et al27 also found that patients who continued to have respiratory distress 48 h after ED discharge were characterized by a lower FEV1 than those who were successfully discharged. These early studies greatly influenced asthma management in the 1980s, particularly the decision on who to admit to the hospital and who to send home. In more recent years, however, Worthington and Ahuja,8 studied 96 patients and found no significant difference in FEV1 between the patients who suffered relapse and those who did not return for further care. Indeed, they found that the spirometric criteria used by Nowak et al,27had a positive predictive value of only 15%. Martin and colleagues28 studied 86 asthmatic episodes and also found that pulmonary function failed to predict relapse, as did we in a study of 91 patients in Cleveland.11 Although consistent, the low statistical power of these small, single-site studies has discouraged conclusions about the predictive role of pulmonary function testing. In the present multicenter study involving > 600 patients, however, we again found that PEFR was not associated with risk for relapse among patients sent home from the ED.

This study was not designed as a prospective randomized trial of pulmonary function testing. The study was designed to identify factors associated with relapse after the discharge decision had already been made. We do not interpret this “negative” finding to indicate that pulmonary function testing is not useful in the ED. Measurement of pulmonary function in the ED is recommended to guide patient management and disposition in recent national29,,30 and international guidelines.31Furthermore, we demonstrated in a prior study that objective measurement of pulmonary function changes ED management in approximately 20% of cases.32The role of PEFR measurement in the participating EDs is undoubtedly obscured by our restricting the analysis to patients in whom a discharge decision had already been made, a decision that was based, to some degree, on the patient’s PEFR. Although some clinicians question the correctness of using PEFR in the ED,33 the present study was not designed to address the actual contribution of pulmonary function testing to therapeutic or admission decisions.

The present analysis identified several historical risk factors for acute asthma relapse. These results are similar to those obtained from three, single-center studies.11,,12,,34 McCarren et al34 observed 284 adult asthmatics for up to 8 weeks and found a 48% relapse rate. They found that patients with three or more ED visits within the prior 5 months, impairment in performing work or activities within the prior 4 weeks, or failure to achieve a PEFR of 50% at time of 24-h discharge from the hospital had a higher incidence of relapse.34 In Cleveland, we followed up 91 patients discharged after ED treatment for acute asthma, and found that patients who suffered relapse within 21 days of their ED visit tended to be younger and were more likely to have a history of ED visits in the previous 3 months.11The results were the same whether we used 3 days or 21 days for our definition of relapse. Similarly, Ducharme and Kramer12 in Montreal followed up 314 children after ED treatment for acute asthma. In their study, 30% of children had a relapse within 10 days, most (68%) within 1 day. Although a number of variables were significantly associated with relapse, only two were retained in the final multivariate model: four or more ED visits in the past year and use of an oral short-acting theophylline preparation during the course of ED treatment. The authors speculate that the latter finding may have been due to prescription of theophylline at ED discharge, but they were unable to test this hypothesis. In both studies,11,,12 the strongest predictor of relapse was frequency of ED visits before the index visit. Although the relapse rate among patients with symptoms > 7 days was not significantly different from the reference group, this finding may reflect a different type of “relapse” among patients with chronic asthma symptoms.

In all of these observational studies, including our own, there has been no apparent relationship between ED treatment with systemic steroids and risk for relapse. Observational studies are quite susceptible to confounding by indication, however, with physicians tending to prescribe steroids to patients with more complex conditions with higher risk of relapse. Further steroid use prior to or during the ED visit may alter the postdischarge effect. Consequently, patients who receive systemic steroids may suffer more relapse events than otherwise expected, an excess that may not be completely reversed by the salutary effects of the prescribed steroids. The role of pharmacologic interventions is much better examined in randomized, double-blinded trials. In the case of systemic steroids, several trials in both adults and children with acute asthma have clearly documented decreases in risk of both hospital admission35,,36,,37,,38,,39 and acute asthma relapse.39,,40,,41,,42

There are several limitations to the present study. First, ED management was not standardized. It is possible that some differences in patient management may have masked factors associated with relapse. Second, the definition of relapse is somewhat arbitrary. We have used an end point of outpatient relapse while some authors have used a combined end point of ED admission or relapse. Moreover, various authors have used follow-up intervals from 48 h to 21 days to define relapse. The difficulty with choosing shorter time periods is that one may miss subsequent relapse events, and recovery of pulmonary function following an asthma exacerbation may take as long as 7 days. Use of longer time periods, however, may introduce contamination by new asthma exacerbations, triggered by reexposure to another asthma precipitant, rather than true relapse from the initial exacerbation. The lack of a standardized definition of relapse represents a limitation of this study and of the literature in general. Third, the results of this study may not be generalizable to a subset of ED patients who were less likely to be contacted for follow-up: black male smokers without a primary care provider. In prior work, however, we have found that lack of an identifiable primary care physician increases the risk of relapse.43 This study was limited to adult asthmatics; factors associated with relapse among pediatric patients may be different. Further, our enrollment was triggered by a physician’s diagnosis of asthma. This operational definition mimics common ED assessment but is not standardized, as might be the case if we had used more vigorous methods of classifying patients.

In conclusion, we found that 17% of adults sent home following ED treatment for acute asthma reported relapse during the 2 weeks after their ED visit. PEFR does not predict relapse among this patient group. Patients at increased risk for relapse have a history of numerous asthma-related ED and urgent clinic visits within the past year, and are using more outpatient asthma medications, including home nebulizers. Patients who have relapses also appear to have longer duration of symptoms. Future research may determine if patients identified by these criteria would benefit from more intensive management of their asthma. Although additional work remains to be done in this area, our work, along with others, suggests that patients at high risk from relapse should be considered for extended treatment, either in an observation unit or an inpatient unit. Compared with inpatient treatment, observation units have been found to have the same relapse rate.19 It remains to be demonstrated convincingly whether identification of high-risk patients and treatment in an observation unit will decrease the relapse rate.

MARC Steering Committee

Carlos A. Camargo, Jr., MD, FCCP (Chair); Rita K. Cydulka, MD; Michael A. Gibbs, MD; Robert A. Silverman, MD; and Janice L. Zimmerman, MD, FCCP.

Operations Committee and Data Coordinating Center

Carlos A. Camargo, Jr., MD, FCCP (Chair); George T. Mathew; Leo T. Mayer; Anita K. Singh; and Prescott G. Woodruff, MD—all at Massachusetts General Hospital, Boston, MA.

Principal Investigators at the 36 Participating Sites

C.A. Bethel (Mercy Hospital, Philadelphia, PA); L. Bielory (University Hospital, Newark, NJ); M.P. Blanda (Summa Health System, Akron, OH); B.E. Brenner (Brooklyn Hospital Center, Brooklyn, NY); C.A. Camargo, Jr. (Massachusetts General Hospital, Boston, MA); R.K. Cydulka (MetroHealth Medical Center, Cleveland, OH); D.J. Dire (University of Oklahoma Medical Center, Oklahoma City, OK); N. El Sanadi (Broward General Hospital, Ft. Lauderdale, FL); S.D. Emond (St. Luke’s/Roosevelt Hospital Center, New York, NY); T.J. Gaeta (St. Barnabas Hospital, Bronx, NY); M.A. Gibbs (Carolinas Medical Center, Charlotte, NC); T.E. Glynn (Brooke Army Medical Center, Fort Sam Houston, TX); L.G. Graff IV (New Britain General Hospital, New Britain, CT); R.O. Gray (Hennepin County Medical Center, Minneapolis, MN); J.P. Hanrahan (Beth Israel Hospital, Boston, MA); F. Harchelroad (Allegheny General Hospital, Pittsburgh, PA); A.H. Idris (University of Florida Health Center, Gainesville, FL); M.E. Johnson (Jackson Memorial Hospital, Miami, FL); L.F. Lobon (Beth Israel Medical Center, New York, NY); M.F. McDermott (Cook County Hospital, Chicago, IL); E.S. Nadel (Brigham and Women’s Hospital, Boston, MA); R.M. Nowak (Henry Ford Hospital, Detroit, MI); E. Paul (Charity Hospital, New Orleans, LA); C.V. Pollack, Jr. (Maricopa Medical Center, Phoenix, AZ); D.J. Robinson (University of Maryland Medical Center, Baltimore, MD); R.M. Rodriguez (Southwestern Medical Center, Dallas, TX); G. Rudnitsky (Allegheny University—MCP Division, Philadelphia, PA); R.E. Sapien (University of New Mexico Health Sciences Center, Albuquerque, NM); D. Schreiber (Stanford University Medical Center, Stanford, CA); R.A. Silverman (Long Island Jewish Medical Center, New Hyde Park, NY); S.A. Stahmer (Hospital of the University of Pennsylvania, Philadelphia, PA); A. Sucov (Strong Memorial Hospital, Rochester, NY); D.M. Taylor (University of Pittsburgh Medical Center, Pittsburgh, PA); C.A. Terregino (Cooper Hospital/University Medical Center, Camden, NJ); D. Travers (University of North Carolina Hospitals, Chapel Hill, NC); and J.L. Zimmerman (Ben Taub General Hospital, Houston, TX).

For editorial comment see page 909.

Drs. Woodruff and Camargo are supported by grants HL-07427 and HL-03533, respectively, from the National Institutes of Health (Bethesda, MD). The Multicenter Asthma Research Collaboration is supported by unrestricted grants from Glaxo-Wellcome Inc (Research Triangle Park, NC) and Monaghan Medical Corporation (Syracuse, NY).

A complete list of the MARC Investigators is located in Appendix 1.

Correspondence to: Charles L. Emerman, MD, Department of Emergency Medicine, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109-1998; e-mail: cemerman@ metrohealth.org

Table Graphic Jump Location
Table 1. Patient Characteristics, According to Relapse Status 2 Weeks After ED Discharge
* 

PCP = primary care provider.

Table Graphic Jump Location
Table 2. PEFR Data, According to Relapse Status 2 Weeks After ED Discharge
* 

Values given as mean ± SD.

Figure Jump LinkFigure 1. Relation of number of ED visits for asthma over past year to relapse rate.Grahic Jump Location
Figure Jump LinkFigure 2. Relation of number of urgent clinic visits for asthma to relapse rate.Grahic Jump Location
Table Graphic Jump Location
Table 3. Univariate Analysis of Factors Associated With Relapse
Table Graphic Jump Location
Table 4. Multivariate Analysis of Factors Associated With Relapse*
* 

The final model included all of the above factors plus age, gender, race (white, nonwhite), and primary care provider (PCP) status (has PCP with recent visit, has PCP without recent visit, does not have PCP).

ACKNOWLEDGMENT: We thank Dr. Frank Speizer for his support, and all of the MARC Investigators for their ongoing dedication to emergency asthma research.

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Banner, AS, Shah, RS, Addington, WW Rapid prediction of need for hospitalization in acute asthma.JAMA1976;235,1337-1338. [PubMed]
 
Nowak, RM, Pensler, MI, Sarkar, DD, et al Comparison of peak expiratory flow and FEV1admission criteria for acute bronchial asthma.Ann Emerg Med1982;11,64-69. [PubMed]
 
Martin, TG, Elenbaas, RM, Pingleton, SH Failure of peak expiratory flow rate to predict hospital admission in acute asthma.Ann Emerg Med1982;11,466-470. [PubMed]
 
National Asthma Education and Prevention Program. Expert panel report II: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, 1997.
 
Beveridge, RC, Grunfeld, AF, Hodder, RV, et al Guidelines for the emergency management of asthma in adults: CAEP/CTS asthma advisory committee: Canadian Association of Emergency Physicians and the Canadian Thoracic SocietyCan Med Assoc J1996;155,25-37
 
Global Initiative for Asthma. Global strategy for asthma management and prevention, National Heart, Lung, and Blood Institute/World Health Organization workshop report. Bethesda, MD: National Institutes of Health, 1995; publication 95-3659.
 
Emerman, CL, Cydulka, RK Effect of pulmonary function testing on the management of acute asthma.Arch Intern Med1995;155,2225-2228. [PubMed]
 
Zemenick, RB Spirometric testing in acute asthma [letter to the editor]. Ann Emerg Med. 1997;;30 ,.:356. [PubMed]
 
McCarren, M, McDermott, MF, Zalenski, RJ, et al Prediction of relapse within 8 weeks after an acute asthma exacerbation in adults.J Clin Epidemiol1998;51,107-118. [PubMed]
 
Littenberg, B, Gluck, EH A controlled trial of methylprednisolone in the emergency treatment of acute asthma.N Engl J Med1986;314,150-152. [PubMed]
 
Stein, LM, Cole, RP Early administration of corticosteroids in emergency room treatment of acute asthma.Ann Intern Med1990;112,822-827. [PubMed]
 
Tal, A, Levy, N, Bearman, JE Methylprednisolone therapy for acute asthma in infants and toddlers: a controlled clinical trial.Pediatrics1990;86,350-356. [PubMed]
 
Schneider, SM, Pipher, A, Birtton, HL, et al High-dose methylprednisolone as initial therapy in patients with acute bronchospasm.J Asthma1988;25,189-193. [PubMed]
 
Scarfone, RJ, Fuchs, SM, Nager, AL, et al Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.Pediatrics1993;92,513-517. [PubMed]
 
Chapman, KR, Verbeek, PR, White, JG, et al Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma.N Engl J Med1991;324,788-794. [PubMed]
 
Fiel, SB, Swartz, MA, Glanz, K, et al Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma.Am J Med1983;75,259-262. [PubMed]
 
Harris, JB, Weinberger, MM, Nassif, E, et al Early intervention with short courses of prednisone to prevent progression of asthma in ambulatory patients incompletely responsive to bronchodilators.J Pediatr1987;110,627-633. [PubMed]
 
Emerman, CL, Cydulka, RK Behavioral and environmental factors associated with acute exacerbation of asthma.Ann Allergy Asthma Immunol1998;81,239-242. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Relation of number of ED visits for asthma over past year to relapse rate.Grahic Jump Location
Figure Jump LinkFigure 2. Relation of number of urgent clinic visits for asthma to relapse rate.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Patient Characteristics, According to Relapse Status 2 Weeks After ED Discharge
* 

PCP = primary care provider.

Table Graphic Jump Location
Table 2. PEFR Data, According to Relapse Status 2 Weeks After ED Discharge
* 

Values given as mean ± SD.

Table Graphic Jump Location
Table 3. Univariate Analysis of Factors Associated With Relapse
Table Graphic Jump Location
Table 4. Multivariate Analysis of Factors Associated With Relapse*
* 

The final model included all of the above factors plus age, gender, race (white, nonwhite), and primary care provider (PCP) status (has PCP with recent visit, has PCP without recent visit, does not have PCP).

References

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Banner, AS, Shah, RS, Addington, WW Rapid prediction of need for hospitalization in acute asthma.JAMA1976;235,1337-1338. [PubMed]
 
Nowak, RM, Pensler, MI, Sarkar, DD, et al Comparison of peak expiratory flow and FEV1admission criteria for acute bronchial asthma.Ann Emerg Med1982;11,64-69. [PubMed]
 
Martin, TG, Elenbaas, RM, Pingleton, SH Failure of peak expiratory flow rate to predict hospital admission in acute asthma.Ann Emerg Med1982;11,466-470. [PubMed]
 
National Asthma Education and Prevention Program. Expert panel report II: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, 1997.
 
Beveridge, RC, Grunfeld, AF, Hodder, RV, et al Guidelines for the emergency management of asthma in adults: CAEP/CTS asthma advisory committee: Canadian Association of Emergency Physicians and the Canadian Thoracic SocietyCan Med Assoc J1996;155,25-37
 
Global Initiative for Asthma. Global strategy for asthma management and prevention, National Heart, Lung, and Blood Institute/World Health Organization workshop report. Bethesda, MD: National Institutes of Health, 1995; publication 95-3659.
 
Emerman, CL, Cydulka, RK Effect of pulmonary function testing on the management of acute asthma.Arch Intern Med1995;155,2225-2228. [PubMed]
 
Zemenick, RB Spirometric testing in acute asthma [letter to the editor]. Ann Emerg Med. 1997;;30 ,.:356. [PubMed]
 
McCarren, M, McDermott, MF, Zalenski, RJ, et al Prediction of relapse within 8 weeks after an acute asthma exacerbation in adults.J Clin Epidemiol1998;51,107-118. [PubMed]
 
Littenberg, B, Gluck, EH A controlled trial of methylprednisolone in the emergency treatment of acute asthma.N Engl J Med1986;314,150-152. [PubMed]
 
Stein, LM, Cole, RP Early administration of corticosteroids in emergency room treatment of acute asthma.Ann Intern Med1990;112,822-827. [PubMed]
 
Tal, A, Levy, N, Bearman, JE Methylprednisolone therapy for acute asthma in infants and toddlers: a controlled clinical trial.Pediatrics1990;86,350-356. [PubMed]
 
Schneider, SM, Pipher, A, Birtton, HL, et al High-dose methylprednisolone as initial therapy in patients with acute bronchospasm.J Asthma1988;25,189-193. [PubMed]
 
Scarfone, RJ, Fuchs, SM, Nager, AL, et al Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma.Pediatrics1993;92,513-517. [PubMed]
 
Chapman, KR, Verbeek, PR, White, JG, et al Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma.N Engl J Med1991;324,788-794. [PubMed]
 
Fiel, SB, Swartz, MA, Glanz, K, et al Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma.Am J Med1983;75,259-262. [PubMed]
 
Harris, JB, Weinberger, MM, Nassif, E, et al Early intervention with short courses of prednisone to prevent progression of asthma in ambulatory patients incompletely responsive to bronchodilators.J Pediatr1987;110,627-633. [PubMed]
 
Emerman, CL, Cydulka, RK Behavioral and environmental factors associated with acute exacerbation of asthma.Ann Allergy Asthma Immunol1998;81,239-242. [PubMed]
 
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