Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial

Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial

PEDIATRICS/BRIEF RESEARCH REPORT Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial E...

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PEDIATRICS/BRIEF RESEARCH REPORT

Initiation of an Inhaled Corticosteroid During a Pediatric Emergency Visit for Asthma: A Randomized Clinical Trial Esther M. Sampayo, MD, MPH*; Maryann Mazer-Amirshahi, PharmD, MD; Elizabeth A. Camp, PhD; Joseph J. Zorc, MD, MSCE *Corresponding Author. E-mail: [email protected], Twitter: @md_ems.

Study objective: We determine whether prescribing an inhaled corticosteroid during a pediatric emergency department (ED) asthma visit increases ongoing use and improves outcomes. Methods: This randomized trial enrolled children aged 1 to 18 years, with persistent asthma not previously prescribed a controller medication, and who were being discharged after ED asthma treatment. Intervention subjects received a 1-month prescription for an inhaled corticosteroid (fluticasone or budesonide by age) in addition to standard asthma therapy and instructions given to all patients. Outcomes included filling of the intervention and subsequent inhaled corticosteroid prescriptions, asthma-related symptoms and quality of life, and follow-up rates with a primary care provider. Outcomes were assessed during telephone interviews 2 and 8 weeks after the ED visit and by review of primary care provider and pharmacy records. Results: One hundred forty-seven children were enrolled, and baseline measures were similar between groups. In the intervention group, 53.5% of patients filled an initial ED prescription for inhaled corticosteroid. There was no important difference between groups in subsequent filling of a primary care provider prescription (21% intervention versus 17% control; relative rate¼1.24; 95% confidence interval 0.63 to 2.41). During the 2 weeks after the ED visit, intervention subjects reported reduced shortness of breath while awake and cough while asleep compared with controls. Groups did not differ by rates of primary care provider follow-up, functional limitations, or asthma-related symptoms and quality of life. Conclusion: There was no difference in the proportion of patients who filled a primary care provider prescription after ED initiation of an inhaled corticosteroid. The intervention was associated with reduced reported symptoms but did not affect other asthma outcomes or primary care provider follow-up. [Ann Emerg Med. 2017;-:1-7.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.01.005

INTRODUCTION Asthma is the most common chronic disease of childhood and a leading cause of emergency department (ED) visits. Concern about the high morbidity of asthma has led to National Asthma Education and Prevention Program guidelines, which recommend controller therapies such as inhaled corticosteroids according to strong evidence for improved outcomes.1 Children treated for asthma in the ED represent a population at high risk for persistent symptoms and disability.2,3 Efforts to improve asthma care after an ED visit have focused on improving follow-up with a primary care provider, but have generally not observed improved long-term outcomes. In response to the continued suboptimal quality of preventive care among patients treated in the ED, the National Asthma Education Volume

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and Prevention Program Guidelines recommend that emergency physicians “consider” initiating inhaled corticosteroid at discharge.1 Importance Although guidelines recommend consideration, little is known about the practice of initiating inhaled corticosteroid for children at discharge from the ED. Surveys of ED providers have found low rates of inhaled corticosteroid prescription.4,5 Concerns expressed about this practice include the potential that the emergency physician cannot provide long-term care and may take on the role of the primary care provider and discourage followup care. However, a case series has suggested that when controller medications are initiated in the ED, they may be Annals of Emergency Medicine 1

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Editor’s Capsule Summary

What is already known on this topic It is unknown whether emergency department (ED) discharge prescription after pediatric asthma treatment of inhaled corticosteroids results in increased long-term inhaled corticosteroid use. What question this study addressed This randomized controlled trial of 147 children aged 1 to 18 years who were treated in an urban academic ED studied whether inhaled corticosteroid prescription at ED discharge was associated with increased filling of a subsequent primary care provider inhaled corticosteroid prescription. What this study adds to our knowledge Only 53.5% of intervention patients filled the ED inhaled corticosteroid prescription. ED inhaled corticosteroids did not increase filling of a subsequent primary care provider inhaled corticosteroid prescription. How this is relevant to clinical practice ED inhaled corticosteroid prescription alone does not improve long-term inhaled corticosteroid use.

continued by the primary care provider.6 Furthermore, an adult study has suggested that initiating controller medications during the ED visit may decrease relapse rates and asthma symptom burden after an ED visit.7 These outcomes have not been thoroughly evaluated in children. Goals of This Investigation Our primary objective was to determine whether initiating an inhaled corticosteroid during an ED visit for acute asthma improved ongoing care as measured by filling of a subsequent controller medication prescription given by the primary care provider. Our secondary outcomes assessed short-term outcomes, including asthma symptoms and measures of functional disability, asthma-related quality of life, and follow-up with a primary care provider. MATERIALS AND METHODS Study Design and Setting This was a randomized controlled trial conducted at an urban academic children’s hospital ED with 85,000 annual visits. This study was approved by the local institutional review board. 2 Annals of Emergency Medicine

Selection of Participants Potential subjects were identified by research staff present between 8 AM and midnight. Inclusion criteria were aged 1 to 18 years; asthma defined as greater than 2 previous wheezing episodes treated with b-agonists; persistent symptoms as defined by the Pediatric Asthma Control Tool, a validated instrument to assess asthma control8; plan for ED discharge; and an identified primary care provider for follow-up. Exclusion criteria were inpatient or observation admission; previous ICU admission for asthma; contraindications to b-agonists or systemic or inhaled steroids; comorbid chronic lung, sickle cell, heart disease, or immunodeficiency; lack of English-speaking guardian or a telephone for follow-up; and previous enrollment. Interventions and Methods of Measurement After informed consent, research staff obtained a study packet with the randomization assignment contained in an opaque, sealed envelope. Packets were randomized in advance in blocks of 6 and stratified by treatment with or without oral corticosteroids and by inhaled corticosteroid age category. Discharge medications other than the study intervention were determined by the ED provider. Control and intervention subjects received standardized asthma education, an asthma action plan, and recommendation for primary care provider follow-up within 5 days. All primary care providers received a fax of the ED medical record. In addition, the intervention group received a prescription for a 1-month supply with no refills of an inhaled corticosteroid according to age and Food and Drug Administration recommendations at the study: for aged 1 to 4 years, budesonide (Pulmicort) respules, 0.5 mg by nebulizer once daily; aged 5 to 11 years, fluticasone propionate (Flovent) hydrofluoroalkane 44 mg, 2 puffs by spacer twice daily; and aged 12 to 18 years, fluticasone propionate (Flovent) hydrofluoroalkane 110 mg, 2 puffs by spacer twice daily.1 All study participants received a $15 gift certificate. Data Collection and Processing and Outcome Measures During the ED visit, study staff surveyed subjects about demographic characteristics, asthma history, current medication(s), and sites for primary care and pharmacy prescription fills. Subjects also completed the Integrated Therapeutics Group Child Asthma Short Form, an 8-item previously validated instrument to measure asthma-related symptoms and quality of life.9 Participants were contacted by telephone at 2 and 8 weeks after the ED visit by study staff blinded to group Volume

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assignment to measure patient’s symptoms, medication use, functional limitation, primary care provider followup, and return ED visits. We readministered the Integrated Therapeutics Group Child Asthma Short Form at 2 weeks and 8 weeks and the Pediatric Asthma Control Tool at 8 weeks. At study conclusion, we reviewed primary care provider electronic medical records and requested faxed medical chart copies from providers outside of our system. A research team member with pharmacy training (M.M.-A.) who was blinded to group allocation conducted telephone interviews with patients’ self-identified preferred pharmacies to determine asthma prescriptions filled in the 8 weeks after the ED visit. If no information was available at the reported pharmacy, asthma medication prescription data were solicited from the national pharmacy chain databases; insurance claims, from the largest Medicaid provider in this population. Primary Data Analysis Sample size was calculated with data from a previous study. With power defined at 80%, a¼.05, and a 2-sided test, a total sample size of 132 was calculated to detect a proportion difference of 0.25 between the control and intervention groups. Goal sample size was increased to 150 to account for a 10% loss to follow-up. Statistical analysis was conducted with SPSS (version 20; IBM Corp, Armonk, NY). Descriptive differences between control and intervention groups were determined with the Pearson’s c2 test for categorical variables (Fisher’s exact test if any cell value was less than 5) and the Mann-Whitney test for the comparison of medians in continuous, non-normally distributed data. We used the Theil-Sen median technique in Stata (version 13; College Station, TX) to estimate confidence intervals (CIs) for the difference between medians of symptoms reported in telephone follow-up. Effect estimates were calculated with odds ratios and 95% CIs for prescription compliance. Further group comparisons looked at associations between asthma symptoms, quality of life, prescription filling practices, relapse to the ED, and primary care provider follow-up. Statistical significance was defined as a<.05. RESULTS Between 2006 and 2009, 1,758 children were assessed for eligibility; 1,520 (86%) met exclusion criteria. Caregivers of 147 patients (62% of those eligible) consented and were randomized to the 2 treatment groups (Figure). The intervention and control groups were statistically similar by demographic characteristics and Volume

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asthma history (Table 1). Overall, all patients randomized demonstrated poor asthma control, with 22% reporting daily rescue albuterol use and a median of 2 previous ED visits for both groups. Oral steroids were prescribed in the ED for 84% of participants, with similar rates in both groups. Protocol violations included 4 patients in the intervention group who did not receive an ED inhaled corticosteroid prescription and 9 in the control group who received an inhaled corticosteroid prescription provided by ED clinicians outside of the study protocol. All were included in their randomization group for analysis according to intention to treat. For 21 participants, primary care provider medical record copies could not be obtained for verification; pharmacy record verification was completed for all. Sixty-seven percent of control and 64% of intervention subjects had filled at least one asthma medication in the patients’ self-identified preferred pharmacies queried. Follow-up telephone calls were completed for 80% of participants at 2 weeks and 70% at 8 weeks. Among intervention group participants, only 38 (53.5%) filled the inhaled corticosteroid prescription from the ED. A total of 15 patients (21.1%) in the intervention group filled a subsequent prescription from a primary care provider compared with 13 patients in the control group (17.1%), and these rates did not differ (relative rate¼1.24; 95% CI 0.63 to 2.41). Patients who received ED inhaled corticosteroid prescription and followed up with a primary care provider had higher rates of ongoing prescription and refill compared with those who did not follow up, 45% versus 24% (relative risk¼1.5; 0.9 to 2.5). Sensitivity analysis using per-protocol treatment analysis was performed to assess the effect of protocol violations on results; there was no change in the primary outcome. Intervention participants reported 2 fewer median days of symptoms compared with controls for daytime shortness of breath and nighttime cough. CIs for the differences between medians for symptoms as calculated by the TheilSen median technique are displayed in Table 2. Because of differences in the power of these nonparametric tests, the CIs include 0 for variables where the Mann-Whitney U test found statistical significance. Reported rescue albuterol use at 2 weeks in the intervention group was less than for controls (relative risk¼0.6; 95% CI 0.4 to 0.8). At 8 weeks, there was no difference between the control and intervention groups in persistent asthma symptoms, unscheduled ED or primary care provider visits, or qualityof-life assessments (Table 3). To address concerns that prescribing controller medications in the ED might reduce the likelihood of Annals of Emergency Medicine 3

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Inhaled Corticosteroid for Pediatric Asthma Intention-to-Treat Analysis Assessed for eligibility 03/30/06 – 11/09/09 n=1758

Enrollment

Ineligible: n=1520 1112 Not persistent asthma 237 On controller 130 Hospitalized/prior PICU admits 18 Non-English speaking guardian 23 Other or unknown reasons

Paents met eligibility criteria n=238

Follow-up

Randomization

n=91 declined consent Randomized n=147 Allocated to the Control Group ppp n=76

Medical records reviewed n=64

Allocated to the Intervenon Group n=71

Medical Record Verificaon

Medical records reviewed n=62

PCP visit 29/62 (46.8%)

PCP visit 29/64 (45.3%)

Pharmacy Verificaon

Analysis

Had a PCP ICS RX Filled 13/76 / (17.1%))

Had a PCP ICS RX Filled 15/71 / (21.1%))

PICU: Pediatric intensive care unit, PCP: Primary care provider, RX: Prescripon

Figure. Consolidated Standards of Reporting Trials (CONSORT) diagram of patients screened and enrolled in the inhaled corticosteroid asthma study.

follow-up with a primary care provider, we compared followup rates between the control and intervention group and found no difference (relative rate¼1.0; 95% CI 0.7 to 1.5). LIMITATIONS This study was conducted in a single urban center and may not be generalizable to other settings. Protocol violations occurred for 9% of participants but were analyzed by intention to treat. We excluded non–Englishspeaking families; however, this group consisted of only 1.2% of the ineligible population. There was a 30% loss to follow-up on telephone interviews at 8 weeks. Participants were not blinded to 4 Annals of Emergency Medicine

intervention group, and secondary outcome measures were based on parental recall, which may have been influenced by social desirability bias. Although we followed a rigorous pharmacy verification procedure, there is the possibility that some prescription fills were missed. Moreover it is possible that patients who did not follow up with their primary care provider received refills elsewhere or did not fill the prescription within the timeframe of the study follow-up. DISCUSSION To our knowledge, this is the first randomized controlled trial conducted with children and examining Volume

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Table 1. Demographic comparison of all randomized subjects (n¼147).

Demographics Age, y Missing Sex Male Missing Ethnicity Hispanic Non-Hispanic Missing Race White Black Other Missing Any asthma hospitalization Yes Missing Rescue albuterol use Never 1–2 times/mo 1–2 times/wk Every other day Every day More than once a day Missing No. of previous ED visits (1 y) Missing No. of previous oral steroid (1 y) Missing Child currently out of albuterol No Yes Missing No. of previous admissions (1 y) 0 1 2 Missing Has an asthma specialist No Missing

Control, n[76, Median (IQR) or No. (%)

Intervention, n[71, Median (IQR) or No. (%)

4.0 (2.3, 5.9) 0

3.6 (2.0, 7.0) 0

47 (61.8) 0

35 (49.3) 0

5 (6.8) 69 (93.2) 2

3 (4.4) 65 (95.6) 3

2 (2.6) 70 (92.1) 4 (5.3) 0

4 (5.6) 65 (91.5) 2 (2.8) 0

37 (48.7) 0

41 (57.7) 0

7 12 17 14 18 8

(9.2) (15.8) (22.4) (18.4) (23.7) (10.5) 0 2.0 (0.0, 4.0) 1 1.0 (0.0, 2.9) 4

4 16 15 11 14 10

(5.6) (22.5) (21.1) (15.5) (19.7) (14.1) 1 2.0 (1.0, 3.8) 2 1.0 (0.0, 2.0) 3

39 (54.2) 33 (45.8) 4

40 (59.7) 27 (40.3) 4

11 (14.5) 17 (22.4) 7 (9.2) 41

16 (22.5) 16 (22.5) 9 (12.7) 30

76 (100.0) 0

70 (98.6) 1

short-term outcomes after initiation of a controller medication during an acute asthma ED visit. The intervention did not increase filling of subsequent primary care provider inhaled corticosteroid prescriptions in the 8 weeks after the ED visit. Compared with controls, intervention participants reported fewer asthma symptoms, including daytime shortness of breath and nighttime cough, as well as less albuterol use during the 2 weeks after the ED visit. There was no difference between the groups in quality-of-life measures or functional disability, and primary care provider follow-up was not affected by the intervention. Volume

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Table 2. Comparison of the number of days of asthma symptoms between groups with and without and ED inhaled corticosteroid prescription. Asthma Symptoms by Number of Days

Median (IQR) Control, n[76

ED ICS RX, n[71

Symptoms while awake Cough 5.0 (1.5 to 12.5) 4.0 (2.0 to Missing 14 15 Wheeze 2.5 (0.0 to 5.0) 1.0 (0.0 to Missing 14 15 SOB 2.0 (0.0 to 5.5) 0.0 (0.0 to Missing 14 15 Symptoms while asleep Cough 4.0 (0.8 to 11.0) 2.0 (0.0 to Missing 14 15 Wheeze 0.0 (0.0 to 4.0) 0.0 (0.0 to Missing 14 15 SOB 0.0 (0.0 to 0.0) 0.0 (0.0 to Missing 14 15

95% CI for Difference

10.0) 1.0 (–1.27 to 3.27) 3.8)

1.5 (–0.28 to 3.28)

2.4)

2.0 (–0.11 to 4.12)

7.0)

2.0 (–0.83 to 4.83)

2.0)

0.0 (–1.03 to 1.03)

0.0)

0.0 (0.0 to 0.0)

SOB, Shortness of breath.

Inhaled corticosteroids are the preferred long-term controller medication for children with persistent asthma and are an essential component of optimal long-term asthma care. National guidelines encourage emergency physicians to initiate controller medications during an ED visit; however, there is limited evidence to support this practice.1 Multiple studies of inner-city children demonstrate high ED utilization; therefore, some believe an ED visit represents an ideal opportunity to educate about asthma and initiate long-term medications. However, when surveyed, emergency physicians are reluctant to adopt this practice and believe this is not their responsibility and may infringe on the primary care provider’s role.4,5 Therefore, enhancing the role of the ED in the management of childhood asthma has been a focus of study. Studies targeting improving primary care provider follow-up rates after the ED visit have improved visits, but not long-term outcomes. Some comprehensive interventions have provided follow-up care in the ED and improved long-term outcomes but require resources not readily available in most EDs. Some believe that providing long-term medications in the ED may hinder primary care provider follow-up. However, others argue that follow-up rates after an ED visit are already low and we lose the opportunity of a “teachable moment” to initiate inhaled corticosteroids. Although the primary goal of improving long-term controller use was not observed in this study, a number of results suggest there may be benefit in initiating inhaled Annals of Emergency Medicine 5

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Table 3. Comparison between groups of secondary outcomes assessed by 2- and 8-week telephone follow-up and 8-week medical record review. 2 Weeks Secondary Outcomes

8 Weeks

Control, n[76, No. (%) or Median (IQR)

Intervention, n[71, No. (%) or Median (IQR)

Control, n[76, No. (%) or Median (IQR)

Intervention, n[71, No. (%) or Median (IQR)

4 (6.6) 15 13.0 (6.25, 19.0) 20 11.0 (7.3, 15.0) 4 3.0 (1.3, 4.0) 0

5 (9.1) 16 9.0 (3.0, 16.0) 16 10.0 (8.0, 14.0) 4 2.5 (1.0, 4.0) 1

15 (29.4) 25 13.0 (4.50, 18.0) 32 9.5 (5.0, 14.0) 24

10 (20.4) 22 10.0 (5.0, 15.0) 28 8.0 (4.0, 12.0) 21

ED visit because of asthma Missing ARQOL Incomplete PACT Incomplete Rescue albuterol use Missing PCP FU visit Missing

29 (45.3) 12

29 (46.8) 9

ARQOL, Asthma-related symptoms and quality of life; PACT, Pediatric Asthma Control Tool; FU, follow-up.

corticosteroids in the ED. Patients who followed up with a primary care provider had higher rates of ongoing prescription and refill. This is similar to the results of a study that reported that primary care providers continued 75% of inhaled corticosteroid prescriptions that were initiated during an ED visit.6 ED inhaled corticosteroid prescription may be one part of more comprehensive intervention to improve long-term care for high-risk children with asthma. A recent national survey, as well as qualitative work, suggests that primary care providers support the practice of emergency physicians’ initiating inhaled corticosteroid.10,11 The finding of improved symptoms in the weeks after an ED visit among children prescribed an inhaled corticosteroid is consistent with the findings of Rowe et al,7 who observed a reduction in symptom scores and decreased b-agonist use in adults. This should be explored in further research because improved short-term symptoms may be an additional rationale for ED providers to prescribe controller medications. Recent research suggests that filling of asthma medications after a hospitalization is correlated with outcomes such as readmissions.12 Future research could explore this benefit further in the ED and evaluate the potential for dispensing inhaled corticosteroids or providing refills from the ED to further improve short-term recovery and encourage ongoing use. In summary, initiating inhaled corticosteroids for children discharged from the ED after treatment for asthma did not increase subsequent filling of primary care provider–initiated inhaled corticosteroid prescriptions. Future research could further explore the short-term effect on symptoms and outcomes of initiating inhaled corticosteroids in the ED and assess more comprehensive methods to improve follow-up care and prescription filling in high-risk children with asthma. 6 Annals of Emergency Medicine

The authors acknowledge Keystone Mercy, Nicholas Crognale Endowed Chair in Emergency Medicine Funds, Amber Chew, DO, Joseph Mechak, MD, F. Jonathan Skilton, Robert Mcloughlin, MD, Megan Wolfe, MD, and Richard Scarfone, MD. Supervising editor: Kelly D. Young, MD, MS Author affiliations: From the Baylor College of Medicine, Section of Emergency Medicine, Texas Children’s Hospital, Houston, TX (Sampayo, Camp); Perelman School of Medicine at the University of Pennsylvania, Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA (Zorc); and the Department of Emergency Medicine, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC (Mazer-Amirshahi). Author contributions: EMS conceptualized and designed the study, collected data, performed the initial analysis and interpretation of data, drafted the initial manuscript, and approved the final manuscript as submitted. MM-A collected data, revised the manuscript for important intellectual content, and approved the final manuscript as submitted. EC performed the statistical analysis, revised the manuscript for important intellectual content, and approved the final manuscript as submitted. JZ conceptualized and designed the study, interpreted the data, revised the manuscript for important intellectual content, and approved the final manuscript as submitted. EMS takes responsibility for the paper as a whole. All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships Volume

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in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Publication dates: Received for publication February 24, 2016. Revisions received June 23, 2016; October 26, 2016, and November 21, 2016. Accepted for publication January 6, 2017. Presented at the Eastern Society For Pediatric Research, March 2011, Philadelphia, PA; the Pediatric Academic Society National Conference, May 2011, Denver, CO; and the American Academy of Pediatrics National Conference, September 2010, San Francisco, CA. Trial registration number: NCT00294398

REFERENCES 1. National Asthma Education and Prevention Program. Expert Panel Report III: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007. 2. Stevens MW, Gorelick MH. Short term outcomes after acute treatment of pediatric asthma. Pediatrics. 2001;107:1357-1362. 3. Benito-Fernandez J, Onis-González E, Alvarez-Pitti J, et al. Factors associated with short-term clinical outcomes after an acute treatment of asthma in a pediatric emergency department. Pediatr Pulmonol. 2004;38:123-128.

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4. Scarfone R, Zorc J, Angsuco CJ. Emergency medicine physicians’ prescribing of asthma controller medications. Pediatrics. 2006;117:821-827. 5. Andrews AL, Teufel RJ, Basco WT. Initiating inhaled steroid treatment for children with asthma in the emergency room: current reported prescribing rates and frequently cited barriers. Pediatr Emerg Care. 2013;29:957-962. 6. Lehman HK, Lillis KA, Shaha SH, et al. Initiation of maintenance antiinflammatory medication in asthmatic children in a pediatric emergency department. Pediatrics. 2006;118:2394-2401. 7. Rowe BH, Bota GW, Fabris L, et al. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized control trial. JAMA. 1999;281:2119-2126. 8. Zorc JJ, Pawlowski NA, Allen J, et al. Validation of an instrument to measure asthma control in children. J Asthma. 2006;43:753-758. 9. Bukstein DA, McGrath MM, Buchner DA, et al. Evaluation of a short form for measuring health-related quality of life among pediatric asthma patients. J Allergy Clin Immunol. 2000;105:245-251. 10. Sampayo EM, Agnant J, Chew A, et al. Urban primary care physicians’ perceptions about initiation of controller medications during a pediatric emergency department visit for asthma. Pediatr Emerg Care. 2012;28:8-11. 11. Sampayo EM, McLoughlin RJ, Tsevdos D, et al. Pediatricians support initiation of asthma controller medications in the emergency department: a national survey. Pediatr Emerg Care. 2015;31:545-550. 12. Kenyon CC, Rubin DM, Zorc JJ. Childhood asthma hospital discharge medication fills and risk of subsequent readmission. J Pediatr. 2015;166:1121-1127.

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