title: Emergency care re-attendance for acute childhood asthma in a low-resource setting: The Childhood Asthma Re-attendance Assessment (CARA) Study
Creators: name: Ardura Garcia, Cristina
Publisher: name: University of Liverpool Repository
Year: 2018

description: Background Asthma is a public health problem in Latin America, where asthmatic children are mainly treated at emergency rooms during acute attacks. These attacks result in loss of lung function and quality of life for the asthmatic child and family, risk of death and high direct and indirect economic costs. In order to improve paediatric asthma management in Esmeraldas, Ecuador, we aimed to identify predictors of recurrent asthma attacks requiring emergency care and to explore the caregivers’ (CGs) and health care workers’ (HCWs) perceptions of barriers and facilitators to asthma health and home care access. Methods First, a systematic review and meta-analysis of published studies analysing predictors for emergency department (ED) re-attendance or hospital readmission for acute asthma in children was performed. Second, a prospective cohort study of children treated for an asthma attack at an emergency room in Esmeraldas, Ecuador, was undertaken to define the characteristics of these children, determine the rate of ED re-attendance for acute asthma and identify the predictors for this to occur. Third, a qualitative study to explore acute asthma significance and perceived barriers and facilitators for health and home care access from the asthmatic children’s CGs’ and HCWs’ perspective was performed. Results In both the meta-analysis and prospective cohort study, children of a younger age and a history of severe asthma attacks during the previous year were at a greater risk of ED re-attendance for acute asthma. Forty six percent of the children recruited during the prospective cohort suffered a subsequent asthma attack requiring emergency care in the following 6 months. Other identified predictors of ED re-attendance for acute asthma were: existing asthma diagnosis (AOR: 2.17, 95% CI: 1.19-3.94; AHR: 1.66, 95% CI: 1.15-2.39); food triggers (AOR: 1.99, 95% CI: 1.11-3.55); existing eczema diagnosis (AOR: 4.22, 95% CI 1.02-17.54); and urban residence as protective (AHR: 0.69, 95% CI: 0.50-0.95). Twelve HCWs and 20 CGs participated in the in-depth interviews and focus group discussions, expressing a differing significance of asthma attacks. This difference was also observed between experienced and inexperienced HCWs. Multiple barriers and several facilitators were identified by HCWs and CGs that affect health and home care access for asthmatic children. When shown the predictors of ED-reattendance for acute asthma combined in a risk-assessment tool, both HCWs and CGs reported finding the tool easy to use and understand, as well as a useful aid in the decision-making process concerning asthma treatment and follow-up. Conclusion A combination of several question-based predictors may result in an effective and simple risk-assessment tool to be used at the ED to identify asthmatic children at a higher risk of recurrent severe asthma attacks. Increasing CGs’ and HCWs’ asthma knowledge as well as HCWs’ communication skills, to establish a patient centred approach with a shared decision-making process could mean a difference in the quality of the asthma care in this setting. The use of the described recurrent risk assessment tool could prove useful in this process, as reported by the participants in this study.