Where can I find this paper?

http://www.ncbi.nlm.nih.gov/pubmed/23111345

What is this paper about (what is the research question)?

Can we improve the quality of life of paediatric asthmatic patients using the opportunity to increase their medications offered when they present to the ED?

Summary of the Paper

Design: Prospective cohort study

Objective: To assess the impact of improving control medications on quality of life in children with persistent asthma symptoms attending the PED.

Intervention: initiation or improvement of long term control medication – inhaled corticosteroid –  at discharge from PED following presentation with persistent asthma symptoms (in accordance with national guidelines).

Primary outcome: improvement in “Quality of Life”, defined as validated symptoms and quality of life scores (PACT and ARQoL), ascertained by parental reporting at telephone follow-up at 2 weeks, 6 weeks and 6 months after PED discharge.

Population: Patients presenting to PED of tertiary hospital in Bilbao (Spain) between May-December 2010 with persisent asthma symptoms

• Inclusion: Children aged 1-14 years attending with acute asthma and persistent asthma symptoms with or without control medication
• Exclusion: Children with chronic cardiopulmonary and neuromuscular conditions, children <1 year old, children <2 years old presenting with first episode of wheeze, children whose asthma control medication had been modified in preceding 4 weeks.

Results: 1954 asthma episodes of which 164 had persistent symptoms. 146 were included in the study with 22 lost to follow-up. At presentation, 50 (40.3%) were receiving maintenance treatment.

Asthma control medication was initiated in 74 patients (59.7%), improved within the same “step” in 36 (29.0%) and “stepped up” in 14 (11.3%).

Average PACT categorisation at 6 weeks was significantly lower than at 2 weeks (median 12, IQR 13.3 versus median 7.8 IQR 10, p<0.001) with improvement sustained at 6 months.

Mean ARQoL scores at 6 weeks and 6 months were significantly higher than those at 2 weeks (91.9 +/- 11.0 and 93.0 +/- 10.0 versus 86.1 +/- 14.3, p<0.001)

Authors’ Conclusions:

Where long term asthma control medications were initiated or stepped up following PED visit, children showed a decrease in persistent symptoms and improvement in quality of life.

On the study design

The lack of control group in this paper is a major downfall; children were presenting with intercurrent illness, a major confounder. We know from practice that asthma exacerbations are often associated with viral infection, and that wheeze and cough can persist for a few weeks afterwards. It is not surprising, then, that children were better 6 weeks and 6 months after attendance than at 2 weeks. How meaningful are these outcomes? It might be more useful to match patients with controls and demonstrate improvement, ideally through less subjective variables (time off school, hospital reattendance).

There is a risk of inclusion bias considering the seasonal recruitment.

The other issue is with data processing; subjective scores are qualitative or ordinal data at best. The study design seems to convert this to quantitative non-normal data for analysis. There is also significant confusion between averages: the authors state that “the mean PACT categorization was significantly lower”, then provide data for a median. These descriptive variables are suitable for different types of data; what kind of data did the authors have? I am no statistician but it does make me wonder whether they knew what they were doing – and whether we can trust their results and analysis.

What were the results and what does this mean?

It appears that the patients in the study had better quality of life and fewer asthma symptoms at 6 weeks and 6 months than at 2 weeks after PED discharge. However, the validity of this data is uncertain and even if the apparent improvement is reflected in real life, the lack of control group means we cannot attribute it to the introduction or adjustment of asthma medication.

What can we take from this paper into clinical practice?

Unfortunately, very little more than the idea that there might be a role for reviewing asthma medications in PED, in conjunction with a primary care physician.

More questions to ask

• If we introduce a control group for comparison, does the adjustment or introduction of control medication improve quality of life/asthma symptoms?
• Does this translate into objective outcomes such as reduced annual ED attendances/reduced school time missed?

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