Effects of Pediatric Asthma Education on Hospitalizations and Emergency Department Visits: A...
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Transcript of Effects of Pediatric Asthma Education on Hospitalizations and Emergency Department Visits: A...
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
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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
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Research Question
Compared to usual care, does the provision of asthma education to children and their parents reduce Asthma ED visits? Asthma hospitalizations?
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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)
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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
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Methods Calculated pooled findings for
Odds of an event ED visit Hospitalization
Mean Number of events ED visits Hospitalizations
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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)
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QUESTIONS?
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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
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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
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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