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Factors associated with patient visits to the emergency department for asthma therapy in Pakistan

Factors associated with patient visits to the emergency department for asthma therapy in Pakistan Background: Acute asthma is a chronic condition affecting people of all ages around the world and hence, is one of the leading causes of emergency department (ED) visits and hospital admissions globally. Most of them are related to poor patient practices and a weak healthcare system. The aim of our study was to assess the reasons for the increased usage of the ED by asthmatic patients in Pakistan. Methods: A cross-sectional study was conducted on 600 asthmatic patients reporting to the ED of Civil Hospital Karachi over a 6-month period. The consenting patients were given a questionnaire to fill and the following data was collected: demographic information, duration of the disease, medications prescribed the, frequency of and reasons for outpatient clinic and ED visits for issues related to asthma. Result: According to our results most of the participants visited the ED to obtain a nebulized bronchodilator (90 %) or oxygen (79.5 %). Moreover, 44.8 % of the people visited the ED to get treatment without any delay and 24.0 % considered that the severity of asthma does not allow the patient to wait for clinic visits. Strikingly, 92.8 % claimed that inhaled corticosteroid therapy treatment should be stopped when patients feel better. Irregular follow ups with clinics, low education about asthma and an education level higher than a Bachelors degree were the most important factors associated with three or more ED visits per year, p values = 0.0289, 0.0110 and 0.0150 respectively. Conclusion: This study identifies several preventable risk factors responsible for recurrent visits to the ED by asth- matic patients in Pakistan. Keywords: Emergency department, Asthma, Inhaled corticosteroids, Pakistan that the figure may have risen to 334 million. Asthma Background is the most common chronic disease amongst children Asthma is defined as a chronic inflammatory disorder of according to the WHO [2]. Globally, asthma has affected the airways that leads to symptoms like wheezing, cough- 5–10 % of entire population; which has increased greatly ing, breathlessness and tightness of chest, especially at in last 20 years [2]. In 2010, its prevalence reached to just night or in the morning [1]. It is a common condition that over seven million. It was also responsible for 640,000 affects people of all ages throughout the world. Accord - Emergency department (ED) visits, 6.7 million private ing to the World Health Organization (WHO), 235 mil- office visits, and 157,000 hospital admissions in 2007 [ 3]. lion people suffered from asthma worldwide. However, There is not much data available overall for Pakistan but recent figures from the Global Asthma Report 2014 show some figures are present in relation to the child popula - tion. Its prevalence in the pediatric population in Paki- *Correspondence: bilalmemon_744@hotmail.com stan has increased from 5 to 20 % in the last 20 years [4]. Dow University Of Health Sciences, Karachi, Pakistan Full list of author information is available at the end of the article © 2016 Bilal et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/ zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 2 of 6 Acute asthma is one of the leading causes of ED visits statistics, such as means, standard deviations, or median and hospital admissions globally [5–7]. Previous studies were employed to outline age and duration of asthma showed that there were an estimated two million asthma- disease. Percentages were also used to indicate gender, related ED visits and 480,000 asthma-related hospitaliza- ICS use, follow up with clinics, general education level, tions in the United States in 2009 alone, with an annual education about medications, education about asthma, cost of approximately $56 billion [8–10]. There are many and reasons for visiting the ED. Moreover, in order to causes for the large number of ED visits by asthmatic compare the distributions of asthma disease duration patients. Some of the major ones are duration of symp- across number of asthma-related ED visits (<3 versus toms, poor adherence to medications, lack of awareness ≥3), Mann–Whitney test was applied. The associations about the disease, low socioeconomic status, previous between gender, ICS use, follow up with clinics, general hospitalizations or ED consultations, lack of parental education level, education about medications, and educa- confidence in the medications, allergen exposure, lack tion about asthma across asthma-related ED visits were of health insurance, single-parent and crowded families determined by Chi square test. Multiple logistic models [11–16]. were also employed to assess the risk factors that were The increased use of the ED as first-choice of care by linked with three or more asthma-related ED visits. p val- asthmatic patients’ needs to be discouraged because ues less than 0.05 were considered significant. The odds they are an unnecessary and preventable burden on ratios (ORs) with 95  % CIs were further considered to resources that could be better utilized elsewhere. It is report the strength of these associations. therefore important to identify the factors and prob- lems in our healthcare system that are responsible for Results this trend so that we can address them and save valuable A total of six hundred (N  =  600) asthmatic patients resources. The aim of our study is to assess the reasons were selected by non-probability convenience sampling for the increased usage of the ED by asthmatic patients in this cross sectional study. Out of 600 participants, in Pakistan. 186 (31.0  %) were males and 414 (69.0  %) patients were females. Table  1 depicts the demographic and clinical Methodology characteristics of study participants. The mean patients’ This cross-sectional study was conducted from Septem - age was 47.1  ±  18.7  years, and the mean duration of ber 2014 to February 2015 on 600 patients reporting to asthma illness was 147.67  ±  123.19  weeks. Moreover, the ED of Civil Hospital Karachi. It was approved by the only 30  % (N  =  180) of the patients had regular fol- Institutional Review Board of Dow University of Health low up with the physician, while 70  % (N  =  420) of the Sciences (DUHS). The inclusion criterion was such that patients did not have any follow up after their diagnosis patients with a reported diagnosis of asthma and on pre- of asthma. Three hundred and ninety (65.9) patients did scribed inhaled corticosteroids (ICS) for a minimum of not have any formal education about asthma, whereas 5 months were recruited for the study. Patients not hav- 70.4 % (N = 422) were uneducated with regards to usage ing a reported diagnosis of asthma by a physician, not on of devices and medications. Of 210 patients who received ICS therapy or suffering from any illness that they were education about asthma as a disease, 55.0  % acquired it seeking medical care for or other chronic respiratory from physicians, 13.8  % from asthma educators and the illnesses, like chronic obstructive pulmonary diseases rest from pharmacists. Similarly, when patients were (COPD), were omitted from the study. The consenting enquired about the reason for ED visit, it was found patients were given a questionnaire to fill in the ED by that 90.0  % visited to obtain a nebulised bronchodilator, the co-investigators. It had questions pertaining to their 79.5 % to obtain oxygen, 44.8 % to get treatment without demographic information and socioeconomic status. any delay while 24.0 % considered that severity of asthma Also, their education about the disease was evaluated does not allow the patient to wait for clinic visit. Strik- from the following questions—duration of the disease, ingly, 83.0  % of the participants were unaware about the medications prescribed and adherence to them and the factors that trigger symptoms of asthma and 92.8  % the method of use of inhaler devices. They were also claimed that ICS treatment should be stopped when asked about the frequency of outpatient clinic and ED patients feel better. Table  2 depicts knowledge about visits for issues related to asthma. Their files were cross- asthma management and reasons for visiting the ED. checked to compare the information that they provided Furthermore, asthma-related ED visits were stratified with documented visits and confirm its validity. on the basis of whether the asthma patient visited the The data was entered using Social Sciences (SPSS) soft - ED thrice or more for asthma treatment. Table  3 illus- ware program for Windows (version 19.0) and the same trates the relationships between three and more asthma- software was used for statistical analysis. Descriptive related ED visits and the patient’s general education Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 3 of 6 Table 1 Demographic and  clinical characteristics of  study Table 2 Knowledge about  asthma management and  rea- participants sons for visiting ED department Demographic characteristics N % Variable N % Age (years) Mean ± SD 47.1 ± 18.7 Reason for ED visit Duration of illness in weeks (Mean ± SD) 147.67 ± 123.19 Visit ED primarily to obtain a bronchodilator 540 90.0 Gender Visit ED to obtain oxygen 477 79.5 Male 186 31.0 The severity of asthma doesn’t allow the patient to wait for a 144 24.0 clinic visit Female 414 69.0 Belief that the patient is treated faster in the ED 153 25.5 Level of education The ED is available 24 h a day 243 40.5 Matriculation (grade 10) 93 15.5 The patient treated directly without delay 269 44.8 Intermediate (grade 12) 89 14.8 Medication given as nebulizer at ED is more useful 363 60.5 Bachelors 60 10.0 Knowledge about asthma management Masters 39 6.5 Take bronchodilator to relieve symptoms only 534 89.0 No education 319 53.2 Stop ICS therapy when feel better 557 92.8 Profession Believe long term use of inhaler unsafe 183 30.5 Labor 180 30.0 Believe continues use of inhaler cause dependence 244 40.7 Businessman 64 10.7 Believe asthma therapy use its effect overtime 200 33.3 Government employee 122 20.3 Does not know what trigger asthma symptoms 498 83.0 Private employee 142 23.6 Does not know what should do during asthma attack 215 35.8 Housewife 60 10.0 All percentage rounded to one decimal Retired 32 5.4 Follow up regularly with doctor 180 30.0 Follow-up clinic PHC/Family Medicine 129 21.5 Mann–Whitney test shows there was no connection Pulmonary 31 5.2 between the duration of the disease and the number of Internal Medicine 20 3.3 ED visits (p   =  0.546). An education level higher than a No follow-up 420 70.0 Bachelors degree (p value   =  0.0150) and irregular fol- No education about asthma 390 65.0 low up with clinics (p value  =  0.0289) were highly asso- ciated with three or more asthma-related ED visits, after No education about medication (devices) 422 70.4 being controlled for gender, ICS use, general education ED visits level, education about medications, and education about <3 399 66.5 asthma. Our study also indicated that patients with a ≥3 201 33.5 Bachelors degree or higher were twice as more likely to All percentage rounded to one decimal visit the ED than the patients with Intermediate (grade 12) education or less than it (OR: 2.176; 95  % CI: 1.569, 2.783). Moreover, this finding is consistent with patients level, education about asthma, ISC and education about having education about medications (OR: 1.966; 95 % CI: asthma medications. Those who were not educated 1.435, 2.497). It was further revealed that patients who about asthma were more likely to visit the ED because of were not educated about asthma also had greater num- asthma than those who had been educated about asthma ber of visits to the ED for the treatment of their condition (41.5 versus 31.0 %, p value = 0.011). Surprisingly, those (OR: 1.586; 95 % CI: 1.270, 1.902). Table 4 depicts the odd who were more educated about asthma medications and ratios and 95  % CIs for the risk factors associated with had an education level of a Bachelors degree or greater, three or more asthma-related ED visits. exhibited more number of visits to the ED for the treat- ment of asthma (51.8 versus 35.0  %, p value  =  0.017; Discussion 56.9 versus 34.8 %, p value = 0.023). Besides, it was also The results of this study showed that a large percentage revealed that a relationship between patient needing oxy- of the Pakistani population used the ED as a first-choice gen for asthma therapy and three or more ED visits also option instead of keeping follow up appointments with exists (55.5 versus 23.92  %, p value  =  0.0118). However, physicians. These findings are in line with previous stud - there was no correlation between visiting ED primarily to ies conducted in Saudi Arabia, New Zealand and the obtain a bronchodilator and three or more ED visits to United States [17–19]. We also found that patients do treat asthma (33.4 versus 41.8 %, p value = 0.407). not receive much education about the disease they are Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 4 of 6 Table 3 Association between asthma-related ED visits and demographic and clinical characteristics Variable Levels <3 visits ≥3 visits p value (n  = 399) (n  =  201) Gender % Male 62.5 37.5 0.532 Female 64.0 36.0 Regular ICS use Yes 63.8 36.2 0.284 No 61.7 38.3 Follow up with clinics Yes 65.5 34.5 0.366 No 62.3 37.7 Education level Intermediate (grade 12) or less 65.2 34.8 0.023 Bachelors or high 43.1 56.9 Educated about medication Yes 48.2 51.8 0.017 No 65.0 35.0 Educated about asthma Yes 69.0 31.0 0.011 No 58.5 41.5 The Chi square statistic is significant at the 0.05 level. All percentage rounded to one decimal Table 4 Odd ratios and 95 % CIs for the risk factors associated with three or more asthma related ED visit Variable Levels Estimate p value OR 95 % CI Intercept −0.2767 0.4433 Age 0.00364 0.6066 1.015 0.876 1.154 Gender Female 0.0706 0.5397 1.126 0.923 1.329 Regular ICS use No 0.0532 0.7567 1.153 0.965 1.341 Follow up with clinics No −0.2244 0.0289 0.770 0.656 0.884 Education level University 0.4189 0.0150 2.176 1.569 2.783 Educated about medication Yes 0.0810 0.0442 1.966 1.435 2.497 Education about asthma No 0.1943 0.0397 1.586 1.270 1.902 Wald Chi square statistic is significant at the 0.05 level suffering from and the methods of controlling or treat - could be further linked to a limited number of trained ing it. It was evident that 65 % of the population was una- staff in our health care system. Consequently, the number ware about asthma as a disease while around 70  % were of patients visiting the ED for the treatment of asthma uninformed about the medications and devices, such as exacerbations increases greatly. inhalers. These numbers are greater than those of AL- Furthermore, these results highlight major flaws in Jahdali et al., who found that around 52 % of people were our healthcare system and show that there is a desper- uneducated regarding asthma and approximately 41  % ate need for better training of doctors, better education about the medications. There are multiple reasons for the of and easier access to clinics for patients and general- high illiteracy rate related to asthma education. It is due ized awareness programs related to asthma for the com- to a lack of properly trained and educated staff in the ter - munity. A huge problem that we do face is that asthma tiary care hospitals and the low level of education of the patients do not respond to follow ups with the figure patients. Previous studies have suggested that the health- an astounding 70  %. Out of the remaining 30  % who care workers are untrained and lack the basic knowledge do, around 22  % visit the primary care clinic where the regarding the use of inhalation devices, let alone the guidance is unsatisfactory as indicated by work of Abu- more modern methods, hence they are ill-positioned to dahish A et  al. [28] This study conducted in Saudi Ara - guide patients on how to use their medicine [20–23]. It bia found that 40  % of people did not attend any follow has been shown that good asthma control is related to up appointments and of the remaining who did, around patient self-management so it is important to ensure that 46  % attended the primary care clinic [17]. These num - the patient has all the required information to manage his bers point out a huge flaw in the primary healthcare sys - condition [24–27]. Moreover, only 13.8 % of study popu- tem, with asthma management not quite up to scratch. lation received education from asthma educators which Further results from our study showed that there was Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 5 of 6 widespread misconception about using the ED amongst exacerbation of the disease, leading to ED visits. Further- patients with 90  % using it to get a bronchodilator and more, we could not accurately judge the socioeconomic 80 % to get oxygen. These values were comparatively less status of the patients because we only used profession in the study carried out by AL-Jahdali et  al., around 87 and level of education as indicators. Also, a previous and 75 %. These visits were unnecessary, as these medica - study has indicated that people tend to downplay their tions could have been easily obtained from normal clinics level of economic disadvantage when reporting it [29]. too, and utilized precious resources that could have been put to better use, for more critically ill patients. Conclusion Moreover, it is a well-known fact that individuals with This study identified several factors responsible for recur - higher education level have a higher socioeconomic lev- rent visits to the ED for asthma care. The important ones els. As a result they have a better health status due to were patient misconceptions about the use of the ED in the reason that they have greater access to healthcare treating asthma, the lack of education regarding asthma, services. Interestingly, we found that the more educated the lack of adherence to follow up appointments with patients reported three or more visits to the ED, results exclusive asthma clinics and the decreased adherence to that were consistent with a previous study in Saudi Ara- asthma medication. These factors need to be addressed bia [17]. However, unlike that study, patients with knowl- by healthcare workers and there needs to be an overhaul edge about the medication reported more than three at the highest level in order to improve the healthcare visits to the ED [17]. These findings could be explained system. The government also needs to focus more on the by the fact that the patients with asthma experience high education part in primary healthcare rather than giving levels of anxiety, especially during an exacerbation of all their attention to the tertiary sector. It is the only way their symptoms, which may interpret the increased use of to decrease the load on the tertiary care system and pre- ED services, regardless of sociodemographic factors. vent the drainage of important resources. According to our understanding, this study is a first of its kind to be carried out in Pakistan. It was a very exten- Abbreviations sive process involving direct communication with the ED: emergency department; ICS: inhaled corticosteroid therapy; COPD: patients and then confirming the information received chronic obstructive pulmonary disease. with the patient files. It is an important step in the right Authors’ contributions direction because it identifies the frailties in the health - MB, AH, MHK, MS, SD contributed to design of the study, performed statistical care system. Further studies are required in this field so analysis, and drafted the manuscript. MHA, AA, AMW and KMAAJ conceptual- ized the study, participated in its design and coordination, and helped to draft that we can improve the framework for asthma care in the manuscript. All authors read and approved the final manuscript. this country. Author details 1 2 Dow University Of Health Sciences, Karachi, Pakistan. Aga Khan University Limitations Hospital, Karachi, Pakistan. Jinnah Postgraduate Medical Centre, Karachi, This study was carried out only in one hospital so our 4 5 Pakistan. Ziauddin University and Hospital, Karachi, Pakistan. Department sample size was a bit restricted and these results do not of Biological Sciences, The Lyceum, Karachi, Pakistan. Department of Bio- logical Sciences, Karachi Grammar School, Karachi, Pakistan. Department tell the story of the situation in the whole country. The of Biological Sciences, Cedar College, Karachi, Pakistan. patients that we got were mostly from a low socioeco- nomic and relatively illiterate background so we can- Acknowledgements We are thankful to the department of Pulmonology Ward, Civil Hospital Kara- not generalize these results to other patients who might chi for their contributions to this article. have a different knowledge of asthma. Other factors, like access to primary care, may have affected the recurrent Competing interests The authors declare that they have no competing interest. use of the ED but we could not take them into consid- eration due to the unavailability of relevant data. The Received: 12 August 2015 Accepted: 5 January 2016 data was also collected in written form via questionnaires and it might have affected the results as the patients, some of whom were not very educated, might not have References comprehended some of the questions. Therefore, verbal 1. Global Strategy for Asthma Management and Prevention. Global Initiative questioning could be added for better results. We could for Asthma (GINA), 2006. http://www.ginasthma.org Date last updated, also only quantify the education received by the patients 2006. 2. Braman SS. The global burden of asthma. Chest. 2006;130:4S–12S. regarding asthma and not really judge the quality of it. 3. Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, We also did not take into account other environmental and mortality: United states, 2005–2009. Natl Health Stat Report. factors in the daily routine of the patient responsible for 2011;12:1–14. Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 6 of 6 4. Masoli M, Fabian D, Holt S, Beasley R. Global Initiative for Asthma (GINA) 17. AL-Jahdali H, et al. Factors associated with patient visits to the emergency program: the global burden of asthma: executive summary of the GINA department for asthma therapy. BMC Pulm Med. 2012;12:80. 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Factors associated with patient visits to the emergency department for asthma therapy in Pakistan

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Copyright © 2016 by Bilal et al.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Acute asthma is a chronic condition affecting people of all ages around the world and hence, is one of the leading causes of emergency department (ED) visits and hospital admissions globally. Most of them are related to poor patient practices and a weak healthcare system. The aim of our study was to assess the reasons for the increased usage of the ED by asthmatic patients in Pakistan. Methods: A cross-sectional study was conducted on 600 asthmatic patients reporting to the ED of Civil Hospital Karachi over a 6-month period. The consenting patients were given a questionnaire to fill and the following data was collected: demographic information, duration of the disease, medications prescribed the, frequency of and reasons for outpatient clinic and ED visits for issues related to asthma. Result: According to our results most of the participants visited the ED to obtain a nebulized bronchodilator (90 %) or oxygen (79.5 %). Moreover, 44.8 % of the people visited the ED to get treatment without any delay and 24.0 % considered that the severity of asthma does not allow the patient to wait for clinic visits. Strikingly, 92.8 % claimed that inhaled corticosteroid therapy treatment should be stopped when patients feel better. Irregular follow ups with clinics, low education about asthma and an education level higher than a Bachelors degree were the most important factors associated with three or more ED visits per year, p values = 0.0289, 0.0110 and 0.0150 respectively. Conclusion: This study identifies several preventable risk factors responsible for recurrent visits to the ED by asth- matic patients in Pakistan. Keywords: Emergency department, Asthma, Inhaled corticosteroids, Pakistan that the figure may have risen to 334 million. Asthma Background is the most common chronic disease amongst children Asthma is defined as a chronic inflammatory disorder of according to the WHO [2]. Globally, asthma has affected the airways that leads to symptoms like wheezing, cough- 5–10 % of entire population; which has increased greatly ing, breathlessness and tightness of chest, especially at in last 20 years [2]. In 2010, its prevalence reached to just night or in the morning [1]. It is a common condition that over seven million. It was also responsible for 640,000 affects people of all ages throughout the world. Accord - Emergency department (ED) visits, 6.7 million private ing to the World Health Organization (WHO), 235 mil- office visits, and 157,000 hospital admissions in 2007 [ 3]. lion people suffered from asthma worldwide. However, There is not much data available overall for Pakistan but recent figures from the Global Asthma Report 2014 show some figures are present in relation to the child popula - tion. Its prevalence in the pediatric population in Paki- *Correspondence: bilalmemon_744@hotmail.com stan has increased from 5 to 20 % in the last 20 years [4]. Dow University Of Health Sciences, Karachi, Pakistan Full list of author information is available at the end of the article © 2016 Bilal et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/ zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 2 of 6 Acute asthma is one of the leading causes of ED visits statistics, such as means, standard deviations, or median and hospital admissions globally [5–7]. Previous studies were employed to outline age and duration of asthma showed that there were an estimated two million asthma- disease. Percentages were also used to indicate gender, related ED visits and 480,000 asthma-related hospitaliza- ICS use, follow up with clinics, general education level, tions in the United States in 2009 alone, with an annual education about medications, education about asthma, cost of approximately $56 billion [8–10]. There are many and reasons for visiting the ED. Moreover, in order to causes for the large number of ED visits by asthmatic compare the distributions of asthma disease duration patients. Some of the major ones are duration of symp- across number of asthma-related ED visits (<3 versus toms, poor adherence to medications, lack of awareness ≥3), Mann–Whitney test was applied. The associations about the disease, low socioeconomic status, previous between gender, ICS use, follow up with clinics, general hospitalizations or ED consultations, lack of parental education level, education about medications, and educa- confidence in the medications, allergen exposure, lack tion about asthma across asthma-related ED visits were of health insurance, single-parent and crowded families determined by Chi square test. Multiple logistic models [11–16]. were also employed to assess the risk factors that were The increased use of the ED as first-choice of care by linked with three or more asthma-related ED visits. p val- asthmatic patients’ needs to be discouraged because ues less than 0.05 were considered significant. The odds they are an unnecessary and preventable burden on ratios (ORs) with 95  % CIs were further considered to resources that could be better utilized elsewhere. It is report the strength of these associations. therefore important to identify the factors and prob- lems in our healthcare system that are responsible for Results this trend so that we can address them and save valuable A total of six hundred (N  =  600) asthmatic patients resources. The aim of our study is to assess the reasons were selected by non-probability convenience sampling for the increased usage of the ED by asthmatic patients in this cross sectional study. Out of 600 participants, in Pakistan. 186 (31.0  %) were males and 414 (69.0  %) patients were females. Table  1 depicts the demographic and clinical Methodology characteristics of study participants. The mean patients’ This cross-sectional study was conducted from Septem - age was 47.1  ±  18.7  years, and the mean duration of ber 2014 to February 2015 on 600 patients reporting to asthma illness was 147.67  ±  123.19  weeks. Moreover, the ED of Civil Hospital Karachi. It was approved by the only 30  % (N  =  180) of the patients had regular fol- Institutional Review Board of Dow University of Health low up with the physician, while 70  % (N  =  420) of the Sciences (DUHS). The inclusion criterion was such that patients did not have any follow up after their diagnosis patients with a reported diagnosis of asthma and on pre- of asthma. Three hundred and ninety (65.9) patients did scribed inhaled corticosteroids (ICS) for a minimum of not have any formal education about asthma, whereas 5 months were recruited for the study. Patients not hav- 70.4 % (N = 422) were uneducated with regards to usage ing a reported diagnosis of asthma by a physician, not on of devices and medications. Of 210 patients who received ICS therapy or suffering from any illness that they were education about asthma as a disease, 55.0  % acquired it seeking medical care for or other chronic respiratory from physicians, 13.8  % from asthma educators and the illnesses, like chronic obstructive pulmonary diseases rest from pharmacists. Similarly, when patients were (COPD), were omitted from the study. The consenting enquired about the reason for ED visit, it was found patients were given a questionnaire to fill in the ED by that 90.0  % visited to obtain a nebulised bronchodilator, the co-investigators. It had questions pertaining to their 79.5 % to obtain oxygen, 44.8 % to get treatment without demographic information and socioeconomic status. any delay while 24.0 % considered that severity of asthma Also, their education about the disease was evaluated does not allow the patient to wait for clinic visit. Strik- from the following questions—duration of the disease, ingly, 83.0  % of the participants were unaware about the medications prescribed and adherence to them and the factors that trigger symptoms of asthma and 92.8  % the method of use of inhaler devices. They were also claimed that ICS treatment should be stopped when asked about the frequency of outpatient clinic and ED patients feel better. Table  2 depicts knowledge about visits for issues related to asthma. Their files were cross- asthma management and reasons for visiting the ED. checked to compare the information that they provided Furthermore, asthma-related ED visits were stratified with documented visits and confirm its validity. on the basis of whether the asthma patient visited the The data was entered using Social Sciences (SPSS) soft - ED thrice or more for asthma treatment. Table  3 illus- ware program for Windows (version 19.0) and the same trates the relationships between three and more asthma- software was used for statistical analysis. Descriptive related ED visits and the patient’s general education Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 3 of 6 Table 1 Demographic and  clinical characteristics of  study Table 2 Knowledge about  asthma management and  rea- participants sons for visiting ED department Demographic characteristics N % Variable N % Age (years) Mean ± SD 47.1 ± 18.7 Reason for ED visit Duration of illness in weeks (Mean ± SD) 147.67 ± 123.19 Visit ED primarily to obtain a bronchodilator 540 90.0 Gender Visit ED to obtain oxygen 477 79.5 Male 186 31.0 The severity of asthma doesn’t allow the patient to wait for a 144 24.0 clinic visit Female 414 69.0 Belief that the patient is treated faster in the ED 153 25.5 Level of education The ED is available 24 h a day 243 40.5 Matriculation (grade 10) 93 15.5 The patient treated directly without delay 269 44.8 Intermediate (grade 12) 89 14.8 Medication given as nebulizer at ED is more useful 363 60.5 Bachelors 60 10.0 Knowledge about asthma management Masters 39 6.5 Take bronchodilator to relieve symptoms only 534 89.0 No education 319 53.2 Stop ICS therapy when feel better 557 92.8 Profession Believe long term use of inhaler unsafe 183 30.5 Labor 180 30.0 Believe continues use of inhaler cause dependence 244 40.7 Businessman 64 10.7 Believe asthma therapy use its effect overtime 200 33.3 Government employee 122 20.3 Does not know what trigger asthma symptoms 498 83.0 Private employee 142 23.6 Does not know what should do during asthma attack 215 35.8 Housewife 60 10.0 All percentage rounded to one decimal Retired 32 5.4 Follow up regularly with doctor 180 30.0 Follow-up clinic PHC/Family Medicine 129 21.5 Mann–Whitney test shows there was no connection Pulmonary 31 5.2 between the duration of the disease and the number of Internal Medicine 20 3.3 ED visits (p   =  0.546). An education level higher than a No follow-up 420 70.0 Bachelors degree (p value   =  0.0150) and irregular fol- No education about asthma 390 65.0 low up with clinics (p value  =  0.0289) were highly asso- ciated with three or more asthma-related ED visits, after No education about medication (devices) 422 70.4 being controlled for gender, ICS use, general education ED visits level, education about medications, and education about <3 399 66.5 asthma. Our study also indicated that patients with a ≥3 201 33.5 Bachelors degree or higher were twice as more likely to All percentage rounded to one decimal visit the ED than the patients with Intermediate (grade 12) education or less than it (OR: 2.176; 95  % CI: 1.569, 2.783). Moreover, this finding is consistent with patients level, education about asthma, ISC and education about having education about medications (OR: 1.966; 95 % CI: asthma medications. Those who were not educated 1.435, 2.497). It was further revealed that patients who about asthma were more likely to visit the ED because of were not educated about asthma also had greater num- asthma than those who had been educated about asthma ber of visits to the ED for the treatment of their condition (41.5 versus 31.0 %, p value = 0.011). Surprisingly, those (OR: 1.586; 95 % CI: 1.270, 1.902). Table 4 depicts the odd who were more educated about asthma medications and ratios and 95  % CIs for the risk factors associated with had an education level of a Bachelors degree or greater, three or more asthma-related ED visits. exhibited more number of visits to the ED for the treat- ment of asthma (51.8 versus 35.0  %, p value  =  0.017; Discussion 56.9 versus 34.8 %, p value = 0.023). Besides, it was also The results of this study showed that a large percentage revealed that a relationship between patient needing oxy- of the Pakistani population used the ED as a first-choice gen for asthma therapy and three or more ED visits also option instead of keeping follow up appointments with exists (55.5 versus 23.92  %, p value  =  0.0118). However, physicians. These findings are in line with previous stud - there was no correlation between visiting ED primarily to ies conducted in Saudi Arabia, New Zealand and the obtain a bronchodilator and three or more ED visits to United States [17–19]. We also found that patients do treat asthma (33.4 versus 41.8 %, p value = 0.407). not receive much education about the disease they are Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 4 of 6 Table 3 Association between asthma-related ED visits and demographic and clinical characteristics Variable Levels <3 visits ≥3 visits p value (n  = 399) (n  =  201) Gender % Male 62.5 37.5 0.532 Female 64.0 36.0 Regular ICS use Yes 63.8 36.2 0.284 No 61.7 38.3 Follow up with clinics Yes 65.5 34.5 0.366 No 62.3 37.7 Education level Intermediate (grade 12) or less 65.2 34.8 0.023 Bachelors or high 43.1 56.9 Educated about medication Yes 48.2 51.8 0.017 No 65.0 35.0 Educated about asthma Yes 69.0 31.0 0.011 No 58.5 41.5 The Chi square statistic is significant at the 0.05 level. All percentage rounded to one decimal Table 4 Odd ratios and 95 % CIs for the risk factors associated with three or more asthma related ED visit Variable Levels Estimate p value OR 95 % CI Intercept −0.2767 0.4433 Age 0.00364 0.6066 1.015 0.876 1.154 Gender Female 0.0706 0.5397 1.126 0.923 1.329 Regular ICS use No 0.0532 0.7567 1.153 0.965 1.341 Follow up with clinics No −0.2244 0.0289 0.770 0.656 0.884 Education level University 0.4189 0.0150 2.176 1.569 2.783 Educated about medication Yes 0.0810 0.0442 1.966 1.435 2.497 Education about asthma No 0.1943 0.0397 1.586 1.270 1.902 Wald Chi square statistic is significant at the 0.05 level suffering from and the methods of controlling or treat - could be further linked to a limited number of trained ing it. It was evident that 65 % of the population was una- staff in our health care system. Consequently, the number ware about asthma as a disease while around 70  % were of patients visiting the ED for the treatment of asthma uninformed about the medications and devices, such as exacerbations increases greatly. inhalers. These numbers are greater than those of AL- Furthermore, these results highlight major flaws in Jahdali et al., who found that around 52 % of people were our healthcare system and show that there is a desper- uneducated regarding asthma and approximately 41  % ate need for better training of doctors, better education about the medications. There are multiple reasons for the of and easier access to clinics for patients and general- high illiteracy rate related to asthma education. It is due ized awareness programs related to asthma for the com- to a lack of properly trained and educated staff in the ter - munity. A huge problem that we do face is that asthma tiary care hospitals and the low level of education of the patients do not respond to follow ups with the figure patients. Previous studies have suggested that the health- an astounding 70  %. Out of the remaining 30  % who care workers are untrained and lack the basic knowledge do, around 22  % visit the primary care clinic where the regarding the use of inhalation devices, let alone the guidance is unsatisfactory as indicated by work of Abu- more modern methods, hence they are ill-positioned to dahish A et  al. [28] This study conducted in Saudi Ara - guide patients on how to use their medicine [20–23]. It bia found that 40  % of people did not attend any follow has been shown that good asthma control is related to up appointments and of the remaining who did, around patient self-management so it is important to ensure that 46  % attended the primary care clinic [17]. These num - the patient has all the required information to manage his bers point out a huge flaw in the primary healthcare sys - condition [24–27]. Moreover, only 13.8 % of study popu- tem, with asthma management not quite up to scratch. lation received education from asthma educators which Further results from our study showed that there was Bilal et al. Asia Pac Fam Med (2016) 15:1 Page 5 of 6 widespread misconception about using the ED amongst exacerbation of the disease, leading to ED visits. Further- patients with 90  % using it to get a bronchodilator and more, we could not accurately judge the socioeconomic 80 % to get oxygen. These values were comparatively less status of the patients because we only used profession in the study carried out by AL-Jahdali et  al., around 87 and level of education as indicators. Also, a previous and 75 %. These visits were unnecessary, as these medica - study has indicated that people tend to downplay their tions could have been easily obtained from normal clinics level of economic disadvantage when reporting it [29]. too, and utilized precious resources that could have been put to better use, for more critically ill patients. Conclusion Moreover, it is a well-known fact that individuals with This study identified several factors responsible for recur - higher education level have a higher socioeconomic lev- rent visits to the ED for asthma care. The important ones els. As a result they have a better health status due to were patient misconceptions about the use of the ED in the reason that they have greater access to healthcare treating asthma, the lack of education regarding asthma, services. Interestingly, we found that the more educated the lack of adherence to follow up appointments with patients reported three or more visits to the ED, results exclusive asthma clinics and the decreased adherence to that were consistent with a previous study in Saudi Ara- asthma medication. These factors need to be addressed bia [17]. However, unlike that study, patients with knowl- by healthcare workers and there needs to be an overhaul edge about the medication reported more than three at the highest level in order to improve the healthcare visits to the ED [17]. These findings could be explained system. The government also needs to focus more on the by the fact that the patients with asthma experience high education part in primary healthcare rather than giving levels of anxiety, especially during an exacerbation of all their attention to the tertiary sector. It is the only way their symptoms, which may interpret the increased use of to decrease the load on the tertiary care system and pre- ED services, regardless of sociodemographic factors. vent the drainage of important resources. According to our understanding, this study is a first of its kind to be carried out in Pakistan. It was a very exten- Abbreviations sive process involving direct communication with the ED: emergency department; ICS: inhaled corticosteroid therapy; COPD: patients and then confirming the information received chronic obstructive pulmonary disease. with the patient files. It is an important step in the right Authors’ contributions direction because it identifies the frailties in the health - MB, AH, MHK, MS, SD contributed to design of the study, performed statistical care system. Further studies are required in this field so analysis, and drafted the manuscript. MHA, AA, AMW and KMAAJ conceptual- ized the study, participated in its design and coordination, and helped to draft that we can improve the framework for asthma care in the manuscript. All authors read and approved the final manuscript. this country. Author details 1 2 Dow University Of Health Sciences, Karachi, Pakistan. Aga Khan University Limitations Hospital, Karachi, Pakistan. Jinnah Postgraduate Medical Centre, Karachi, This study was carried out only in one hospital so our 4 5 Pakistan. Ziauddin University and Hospital, Karachi, Pakistan. Department sample size was a bit restricted and these results do not of Biological Sciences, The Lyceum, Karachi, Pakistan. Department of Bio- logical Sciences, Karachi Grammar School, Karachi, Pakistan. Department tell the story of the situation in the whole country. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Feb 1, 2016

References