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Original Research: ASTHMA |

Variations and Gaps in Management of Acute Asthma in Ontario Emergency Departments

M. Diane Lougheed, MD, MSc; Nancy Garvey, RRT; Kenneth R. Chapman, MD, FCCP; Lisa Cicutto, PhD; Robert Dales, MD; Andrew G. Day, MSc; Wilma M. Hopman, MA; Miu Lam, PhD; Malcolm R. Sears, MD; Kim Szpiro, MSc; Teresa To, PhD; Nigel A. M. Paterson, MD, FCCP
Author and Funding Information

*From the Queen's University (Drs. Lougheed and Lam), Kingston, ON, Canada; Clinical Research Centre (Dr. Lougheed, Mr. Day, Ms. Hopman, and Ms. Szpiro), Kingston General Hospital, Kingston, ON, Canada; William Osler Health Centre (Ms. Garvey), Brampton, ON, Canada; University of Toronto (Drs. Chapman and Cicutto), Toronto, ON, Canada; University of Ottawa (Dr. Dales), Ottawa, ON, Canada; McMaster University (Dr. Sears), Hamilton, ON, Canada; Child Health Evaluative Sciences (Dr. To), The Hospital for Sick Children, Toronto, ON, Canada; and University of Western Ontario (Dr. Paterson), London, ON, Canada.

Correspondence to: M. Diane Lougheed, MD, MSc, Division of Respirology, Department of Medicine, Queen's University, Kingston, ON, Canada K7L 3N6; e-mail: mdl@queensu.ca

†Currently at the Ontario Ministry of Health and Long-Term Care, Toronto, ON, Canada.

‡For the Ontario Respiratory Outcomes Research Network.


This study was funded by the Canadian Institutes of Health Research (CIHR), the Ontario Thoracic Society, and unrestricted grants from Altana, AstraZeneca, and Boehringer Ingelheim.

Dr. Lougheed has received grants in the last 3 years from the Ontario Ministry of Health and Long-Term Care, Ontario Lung Association, AllerGEN NCE, Topigen Pharmaceuticals, and Ception Therapeutics; and honoraria from GlaxoSmithKline Inc. Epidemiology Advisory Board. Dr. Garvey is currently the Program Coordinator for Ontario Ministry of Health and Long-Term Care's Asthma Plan of Action (effective August 2004, after completion of the study) and refers to the study in presentations related to the Ontario Emergency Department Asthma Care Project. Dr. Chapman has served on the advisory boards or consulted with Astra Zeneca, Boehringer-Ingelheim, GlaxoSmithKline, Novartis, Nycomed, Pfizer, Roche, Schering Plough, Talecris and ZLB Behrig; has undertaken research sponsored or funded in whole or in part by AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Merck Frosst, Novartis, Nycomed, Parangenix, Roche, and ZLB Behrig; and has participated in continuing medical education programs or presentations sponsored by AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Merck Frosst, Novartis, Nycomed, Pfizer, and Talecris. He holds an endowed chair at the University Health Network in Toronto–the CIHR-GSK Chair in Respiratory Health Care Delivery. Dr. Cicutto has received grants from the Ontario Ministry of Health and Long-Term Care, Ontario Lung Association, and consultant fees from Astra Zeneca and GlaxoSmithKline Inc. Dr. Sears provides consulting services and receives speaker fees from AstraZeneca, GlaxoSmithKline, Merck Frosst Canada, and Nycomed (Altana). He has had research funding in the last 3 years from Merck Frosst Canada. Dr. Dales, Mr. Day, Ms. Hopman, Dr. Lam, Ms. Szpiro, and Drs. To and Paterson have no conflicts of interest to disclose regarding the subject matter of this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(3):724-736. doi:10.1378/chest.08-0371
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Background:  Variation in hospitalization rates for acute asthma in Ontario may reflect gaps between evidence and current emergency department (ED) management. We investigated ED management of asthma and differences in practice patterns for pediatric (< 20 years old) and adult (≥ 20 years old) patients in Ontario EDs.

Method:  Patient characteristics and ED management during a 1-year period were assessed by questionnaire and chart abstractions in a stratified sample of 16 Ontario hospitals. Variation between sites was assessed by one-way analysis of variance, Kruskal-Wallis test, or χ2 test.

Results:  Reported results are based on the first of 2,671 pediatric (42.0% female) and 2,078 adult (66.7% female) visits with a corresponding questionnaire. Asthma severity, comorbidities, access to care, and prehospital management varied significantly among sites (all p < 0.001). Documentation of peak expiratory flow (27.2% of pediatric [age ≥ 7] and 44.3% of adult charts), use of systemic steroids in ED (35.2% pediatric and 33.0% adult charts) and on discharge (31.7% pediatric and 33.2% adult charts), and referrals to asthma services (2.8% pediatric and 2.7% adult charts) varied among sites (all p < 0.001). Admission (%) was directly related to time to receive systemic steroids in ED in adults (r = 0.76; p = 0.004). Repeat ED visits (%) were inversely related to new inhaled steroid prescription on discharge in adults (r = −0.64; p = 0.02).

Conclusions:  Knowledge translation initiatives are warranted to increase adherence with best practices in emergency management of asthma (such as objective assessment of airflow rates, use of systemic steroids, and referrals) in order to reduce variations in care and improve outcomes of severe acute asthma.

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