Effects of Pediatric Asthma Education on Hospitalizations and Emergency Department Visits: A Meta-Analysis

June 3, 2007

Janet M. Coffman, PhD, Michael D. Cabana, MD, MPH, Helen A. Halpin, PhD, Edward H. Yelin, PhD

University of California, San FranciscoUniversity of California, Berkeley

Institute for Health Policy Studies

2

Background and Rationale NHLBI guidelines recommend asthma

education for all patients Latest meta-analysis only assessed studies

published prior to 1999 A number of additional studies have been

published over the past eight years Innovations in treatment of asthma Dissemination of NHLBI guidelines

3

Research Question

Compared to usual care, does the provision of asthma education to children and their parents reduce Asthma ED visits? Asthma hospitalizations?

4

Methods Research Design: Meta-analysis Databases:

Cochrane Database of Systematic Reviews Cochrane Register of Controlled Trials PubMed Cumulative Index of Nursing and Allied Health

Literature (CINAHL)

5

Methods Inclusion Criteria

Enrolled children aged 2-17 years with a clinical diagnosis of asthma

Conducted in the United States Compared asthma education to usual care Included a control or comparison group Examined ED visits and/or hospitalizations for

asthma

6

Methods Calculated pooled findings for

Odds of an event ED visit Hospitalization

Mean Number of events ED visits Hospitalizations

7

Methods Analysis

Estimated fixed effects models for all outcomes Conducted Chi-Square test to determine whether

results of the studies pooled are heterogeneous Where results were heterogeneous (i.e., p<0.1 for

Chi-Square test), estimated random effects models

Small number of studies precluded performing meta-regression to explore sources of heterogeneity

8

Results of Literature Search 174 abstracts reviewed 23 articles met the inclusion criteria Research design

19 studies (83%) were RCTs or cluster RCTs 4 (17%) were nonrandomized studies

9

Study Characteristics Demographics: in 16 studies (70%) most of the

children enrolled were low-income Target of intervention: 57% provided education to

both children and parents Types of education: included individual counseling,

group classes, telephone calls, and educational computer games

Types of settings: included outpatient clinics/ physician offices, emergency departments, schools, and homes

10

Odds of ED VisitEducation vs. Usual Care – Fixed Effects

Odds ratio.1 1 10

Study % Weight Odds ratio (95% CI)

0.71 (0.33,1.52) Butz 6.9

0.97 (0.30,3.14) Farber 2.5

0.48 (0.16,1.39) Guendelman 4.5

0.57 (0.28,1.17) Harish 8.9

0.95 (0.55,1.66) JosephMild 11.4

1.12 (0.49,2.57) JosephModSev 4.7

1.21 (0.71,2.08) Lukacs 10.8

0.29 (0.07,1.21) Persaud 3.1

1.49 (0.75,2.95) Shields 6.0

0.62 (0.31,1.23) Sockrider 9.2

0.55 (0.38,0.80) Teach 32.0

0.77 (0.63,0.94) Overall (95% CI)

Test of OR = 1: z = 2.61, p = 0.009; Test of Heterogeneity: χ2 =14.59 (df = 10), p = 0.148

11

Odds of HospitalizationEducation vs. Usual Care – Random Effects

Odds ratio.1 1 10

Study % Weight Odds ratio (95% CI)

0.62 (0.16,2.39) Butz 6.3

0.71 (0.49,1.04) Evans1999 24.3

8.79 (0.43,180.63) Farber 1.5

4.07 (0.44,37.50) Guendelman 2.6

1.03 (0.47,2.26) Harish 13.4

2.50 (0.96,6.54) Lukacs 10.4

0.76 (0.49,1.15) Morgan 22.9

0.51 (0.29,0.90) Teach 18.8

0.87 (0.60,1.27) Overall (95% CI)

Test of OR = 1: z = 0.70, p = 0.482; Test of Heterogeneity: χ2 =13.31 (df = 7), p = 0.065

12

Mean ED VisitsEducation vs. Usual Care – Random Effects

Standardised Mean diff.-3 0 3

Study % Weight Standardised Mean diff. (95% CI)

-1.09 (-2.02,-0.16) Alexander 2.0

0.06 (-0.28,0.40) Bartholomew 8.9

0.10 (-0.53,0.73) Christiansen 3.9

-0.16 (-0.43,0.12) Clark 10.9

-0.78 (-1.58,0.02) Fireman 2.6

-0.44 (-0.79,-0.09) Harish 8.7

0.00 (-0.20,0.20) JosephMild 13.9

-0.06 (-0.43,0.30) JosephModSev 8.3

-0.45 (-0.90,0.00) Kelly 6.4

-0.37 (-1.22,0.47) La Roche 2.4

-1.09 (-2.24,0.06) McNabb 1.4

-0.06 (-0.19,0.08) Morgan 16.3

-0.76 (-1.44,-0.08) Persaud 3.4

0.09 (-0.18,0.37) Shields 11.0

-0.17 (-0.31,-0.03) Overall (95% CI)

Test of SMD = 0: z = 2.40, p = 0.016; Test of Heterogeneity: χ2 =24.48 (df = 13), p = 0.027

13

Mean HospitalizationsEducation vs. Usual Care – Random Effects

Test of SMD = 0: z = 2.53, p = 0.012; Test of Heterogeneity: χ2 =7.68 (df = 4), p = 0.104

Standardised Mean diff.-3 0 3

Study % Weight Standardised Mean diff. (95% CI)

-0.10 (-0.44,0.24) Bartholomew 26.4

-0.37 (-1.00,0.27) Christiansen 13.1

-0.17 (-0.43,0.10) Clark 31.6

-0.79 (-1.59,0.01) Fireman 9.2

-0.77 (-1.23,-0.31) Kelly 19.7

-0.35 (-0.63,-0.08) Overall (95% CI)

14

Possible Reasons for Heterogeneity Although there are not enough studies for

meta-regression, findings for effects on ED visits appear to differ based on Type of education: individual education more

effective than group education Setting: providing education in clinical settings

more effective than providing in school

15

Limitations Only assessed effects on ED visits and

hospitalizations Lack of consistent measures of severity of

asthma symptoms Potential publication bias Results may not generalize to

Upper- and middle-income children Children outside the USA

16

Conclusions and Implications

Pediatric asthma education reduces Odds of an ED visit Mean ED visits Mean hospitalizations

However, in our sample, pediatric asthma education does not affect odds of hospitalization

Health plans should provide incentives for pediatric asthma education

17

Thank You Co-authors

Michael D. Cabana, MD, MPH, UCSF Edward H. Yelin, PhD, UCSF Helen A. Halpin, PhD, UC-Berkeley

Funders California Health Benefits Review Program National Institutes of Health (#HL70771)

18

QUESTIONS?

19

Opportunities for Research Cost-effectiveness of pediatric asthma

education Identification of the most important

components of asthma education Which children benefit most from asthma

education

20

Why Limit Meta-Analysis to US Studies?• Interested in effect of pediatric asthma education on

ED visits• ED utilization depends in part on a country’s health

care system• In the US, many low-income children have poor

access to primary care• Including studies from countries with universal

health care may have confounded the results

21

Comparisons of Different Educational Interventions

Comparisons of different educational interventions suggest that greater reductions in hospitalizations and ED visits were associated with More sessions More comprehensive education More interactive modes of education