Multidisciplinary clinic improves severe asthma outcomes in pediatric patients

Key takeaways:

• The care team included an allergist/immunologist, pulmonologist, pharmacist and other professionals.
• Improvements included FEV₁ totals, oral corticosteroid use and quality of life.

A severe asthma clinic reduced health care utilization and symptom severity for pediatric patients, according to a study published in Annals of Allergy, Asthma & Immunology.

The clinic also improved lung function and quality of life as well as asthma education for these patients, Divya Patel, MD, Rady Children’s Hospital, and colleagues wrote.

Typically, these patients have repeated hospitalizations related to asthma in addition to frequent courses of systemic corticosteroids and symptoms that are difficult to control.

General pediatricians (11.4%), allergy and immunology specialists (35.4%), pulmonologists (22.8%) and inpatient hospitalists/intensivists (30.4%) refer patients to the clinic.

Rady Children’s Hospital established the clinic to address the fragmentation of care and to foster an interprofessional setting where patients who have asthma that is difficult to control can receive comprehensive disease management.

The multidisciplinary team that evaluates each patient includes an allergist/immunologist, a pulmonologist, a clinical pharmacist, a respiratory therapist, a case manager, a nurse practitioner, an asthma educator and a quality improvement analyst.

The study evaluated 79 patients (mean age, 10.7 years; 59% boys; 44% white) who visited the clinic between June 2020 and April 2023, including 51.9% who visited the clinic more than twice.

Comorbidities included allergic rhinitis (91%), allergic conjunctivitis (29%), atopic dermatitis (32%) and food allergy (25%). The multidisciplinary team classified each patient with mild (11.4%), moderate (36.7%) or severe (51.9%) persistent asthma.

The researchers compared the number of ED and urgent care visits, hospitalizations, ICU admissions and oral corticosteroid courses during the 12 months prior to the first visit to the clinic with those totals during the 12 months after the first visit.

The decrease in the number of ED and urgent care visits was significant, the researchers said, with a mean change of 61% or 1.9 to 0.8 visits per patient-year (PPY; P < .001).

Hospitalizations also fell, with a mean change of 67.6% or 0.9 to 0.3 PPY (P < .001), and ICU admissions decreased by a mean change of 77.3% or 0.3 to 0.1 PPY (P < .001).

The reduction in the number of oral corticosteroid courses with a mean change of 59.5%, or 2.8 to 1.1 PPY, was significant as well (P < .001), the researchers continued.

Previous cost-benefit analyses determined that the savings achieved through these reductions in hospitalizations and ED visits covered the costs of regular multidisciplinary interventions.

Spirometry results also improved for 59 patients between their first and most recent visits to the clinic. FEV₁ had a mean change of 7.9% predicted (95% CI, 87.7%-94.6%), and the ratio of FEV₁ to forced vital capacity had a mean change of 4.1% predicted (95% CI, 77.8%-81%).

Patient-reported outcomes (PROs) and quality of life improved for these patients too, with a mean change of 27% and total mean scores falling from 4 to 2.9 (P < .0001), reflecting a minimal clinically important difference of at least one point.

PROs improved overall too for 36 patients, with a mean change of 30.5% and a mean decrease of 21 to 14.9 in PROMIS asthma impact scores (P < .001), which the researchers called important because patients most value asthma control and quality of life.

Patients and/or their caregivers, depending on the age of the patient, completed patient-centered educational modules on disease presentation (module 1), diagnostic evaluation (module 2) and management (module 3) as well.

Pre-module and post-module test scores indicated significant improvements in comprehension, the researchers said, including 7.46% for module 1, 17.86% for module 2 and 20% for module 3 (P < .001).

Based on these findings, the researchers said their synchronous multidisciplinary approach effectively improved the health outcomes of pediatric patients with difficult-to-control asthma.

For example, the researchers noted that 42% of patients began biologics during the study but there were no consistent significant improvements among those patients who used biologics compared with those who did not.

The researchers, therefore, attributed the improvements in PROs, health care utilization and asthma education to the personalized pharmacologic and nonpharmacologic interventions that the patients received at the clinic.

Overall, the researchers attributed the clinic’s success to its collaborative structure, particularly the input of both allergy and immunology specialists who provide insight into allergic diseases and allergy testing and pulmonologists who are experts in chronic lung disease, lung imaging and advanced lung studies.