AL-Jahdali et al.

BMC Pulnunoty Medkine 2O12,

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Pulmonary Medicine

Factors associated with patient visits to the

:::J::::T-i:::Tff: ::,::: : :*ffi

Abdulllah Alshimemerir and Saleh Al-Muhsen3

,:

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Abstract
Background: Acute asthma attack remain a frequent cause of emergency department (ED) visits and hospital
admission. Many frcron encourage pataents to seek asthma treatment at the emergenry department These factor
may be related to the patient himself or to a health system that hinders asthma control. The aim of this study was
to identi0/ the main factors that lead to the frequent admission of asthmatic patients to the ED.
Methods: A cross-sectional survey of all the patients who visited the emergenry room with bronchial asthma
attack over a 9-month period was undefiaken at two major academic hospitals. The followlng data were collected:
demographic data, asthma control in the preceding month, where and by whom the patients were treated, whether
the patient received education about asthma or its medication and the patients' reasons for visiting the ED.

Result Four hundred fifty (N:450) patients were recruited, 39.1% of whom were males with a mean age of 423 t
16.7. The mean duration of asthma was 155.901 127.13 week- Approximately half of the patients did not receive
any information about bronchial asthma as a disease, and 40.7% did not receive any education regarding how to use
asthma medication. Asthma was not controlled or partially controlled in the majority (97.7%) of the patients
preceding the admission to ED. The majority of the patients visited the ED to receive a bronchodilator by nebuliser
{86.7%) and to obtain oxygen (75.1Va}- Moreovet 20.996 of the patienls believed that the ED managed them faster
than the cliniq and 21.1% claimed that their symptoms were severe enough that they could not wait for a clinic visit.
No education about asthma and uncontrolled asthma are the major factors leading to frequent ED visits (three or
more visits/year), pvalue=0.0145 and pvalue=0.0003, respectlvely. Asthma control also exhibited a significant
relationship with inhaled corticosteroid 16 use (pvalue =0.0401) and education about asthma (p-value =0.0117).

Conclusion: This study demonstrates that many avoidable risk factors lead to uncontrolled asthma and ftequent

ED

visits.

Keywords: Asthma, Control, Inhaled cortisone, Emergency department

Background
Asthma is a common condition that affects 5-10% of the
population. The incidence and prevalence of asthma
have increased during i:he past 20 years [1,2J. The prevaIence of brcnchial asthma among Saudi patients is approximately 20-25% [2,3]. Poor asthma control remains

frequent cau$e

Conespondence
'lDepartment

of

emergency departmeat (ED)

Jahdalih@gmail.com

of Medicine, fulnonary Divisior.f,O Kirg Saud Unilerslty for

Health Sciences, Riyadh, Saudi Arabia

tlead of Pulmonary Divi$on, Medical Direcor of Sleep Disorders Center,

Adjunct professor llccill Unilerity, King Saud University for Heakh kbnces,
King Abdulair Medical City, Rifddh, Erydh, Saudi Arabia
Full list of author infonnation is anilable at the end of the article

./- \
( , BiOluled Centfal
\---l

presentation and hospital admission [a]. The cost of uncontrolled asthma care is substantial. For example, the
utilisation of the emergency department for asthma
management accounts for almost one-third of all asthma
costs in the United States [5].
There are many factors that lead patients to visit the
ED. The most common reported factors include as$ma
severity, poor compliance, the inappropriate use of inhaIers, incorrect perceptions about bronchial asthma as a
disease or about its medication, the cost of medication,
lack of an asthma action plan, comorbi&ties, over reli-

ance

on short acting bronchodilators, polludon and

in the weather, the patient's level of education

changes

and low socioeconomic stahrs [5-19].

20 I 2 AL-Jahdali et alj licensee Biolvled Centrdl Ltd- lhis is an Open Acress artide distrihrted under the terms of the
which permir unrest icred u!e.
Geaflve Commons Amibution License (hftp//creati\commons.orglicenses/Bl20l
distribu$on, and reproduction in any medium, pro*ided the original work i! prrydy cired.

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AL-Jahdali

Reducing the use of the ED for acute asthma treat'

ment remains a major goal of asthma management that
is recommended by all grridelines [20-23]. It is not clear
why many patients in our community still visit the ED
and depends on the ED as their primary if not sole
source of care. It is irnportant to understand tJre factors
associated with astlrma-related ED visits in order to reduce the use of ED resource utilization for asthma treatment There are many factors that encourage pa6e.nts to
seek asthma treaknent at the ED and these factors may
be different from one society to another. It is very important to identiff characteristics ofthe patients and de-

ficiencies in our health care delivery system related

factos causing poor asthma contrcl and &requent visits
to the emergency department (ED). The objective of this
study is to evaluate the most imporhnt factors associated with the increased usage of the emergency department in our population

Methods
This was a cross-sectional study conducted at the King
AMulaziz Medical City- King Fahad National Guard
Hospial in Riyadh {KAMC-IGNGH) and the King Khalid University Hospital (IC(UH). We enrolled patients
with diagnosis of asthma who visited the ED for asthma
management between August 2010 and March 2011,
The enrolled patient rnust have a documented diagnosis
of bronchial asthma as diagnosed by their primary treating phlrsician and on prescribed inhaled corticosteroid
(ICS) for at least the last three months. lifle excluded
patients with undocumented diagnosis of bronchial
asthma and not on ICS as per their medical record.
This study was approved by the IRBs of both hospitals
(Ref IRBClf 23fil). During ED visit, the traind co-

investigator collected information about demographic

data, the duration of the illness, the mdication used
for asthma therapy and if the patient received any formal asthma education about asthma as a disease, how
to use their inhaler devices and by whom. The patents
were asked about regular visits to outpatient clinics,
where they follou'ed up, and how many times they visited the emergency department or were hospitalised
oner the last year. C,o-investigators also veri& this information by reviewing the medlcal record of each patient and assess asthma control over the last month by

administering validated published Arabic version af

Asthma Control Test (ACT) [24].
Statistical analysis

The collected dah were transferred and analped using

SAS@ version 9.2 (SAS Institute Inc., Cary, NC). Descriptive statistics, such as means, shndard deviations,
or median were used to summarir.e age and duration of
asthma diseare. Percenages were also used to summarize

Page 2 of 7

gender, ICS use follow up with clinics, education level,

educated about medication, educated about asthma, and
reasons for visiting the ED. Mann-Whitney test was used
to compare the di*tributions of asthma disease duration
across number of asthma-related ED visits (< 3 vs. > 3).
Chi squared tests were used to test the associations between gmdeq, ICS use, follow up with clinics, education

level, educated about medication, and educated about

asthma across asthma-related ED visits. Similu analysis

used

for asthma control test (ACT). Multiple logistic

models were used to identi& the risk factors that associated with three or more asthma'related ED visits. Prralues less than 0.05 were considered sigrrificanl The
odds ratios (ORs) with 95% As were reported to describe the skength of these associations.

Results

Four hundred fffty (n = 450) asthma patients were enrolled in the studp Of the 450 asthma patients, 176
(39.1%) were males a*d 274 (e.9%) were females The

patientt demographic and clinical characteristics are

in Table 1. The mean pa6ents' age was 42.3
116.7 years, and the mean duration of asthma illness
was 155.9O *.127,13 weeks. Two hundred and seventy
(60.0%) patients were regularty followed up with a phys-

shown

ician, urhile 180 (40.096) patients did not have any follow

up arrangement after their initial diagnosis of asthma

Approximately half of the patients did not have any forrnal education about asthma 232 {Slfr%), while 183
(40.7%) did not receive education about how to use the
medication or the devices. Of 218 patients received information about asthma as a disease,445% received this
information ftorn phpicians, 7.8% received the information from asthma educators, and 4.7% neceid the information from a pharmacisL One hundred sixty five of the
450 patieats (i63%) vi$itd the ED three or nore per
year. The patients'asthma control for the last mondr before the ED visit was as follows: 23,4% af the patients
with uncontrolled asthma (ACT score < L5), 74.4% of the

patients with partial controlled asthma (f6 < ACT

23), 1.8% of fie patients with complete controlled asthma (ACT score > 24), and 0.5% of the
patients with missing ACT score. When the patients
score <

were asked about the reason for the ED vi$it, the majority of the patients 86.7% indicated that receiving a nebulised bronchodilator was the maior reason Three
hundred rhirfy-eight (75.1%) patients mentioned obtaining oxygen as their reason, mhile 20.9% believed that
the ED treated their asthma fastex, and 21.1% daimed
that their asthma was severe enough that they could
not wait to visit the clinic (Table 2). The majority of
the patients, 74,7%, did not know what triggered their
asthrna, and 81.6% stopped all asthma therapy once
they felt better.

rN

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AL-Jahdali

Page 3 of 7

I Patient demogr+hics and dinkal asthma

draracteristlcs (t{ = 450}

Tabb

42i*.167

Age,(tt@n!9)
Duration of illnes in weeks (Mean

5D)

155.90r r27.13)

Gender

% Fenale

@-9

Education level

,'/p sd,rp,l

4.0'

High rchod or

42.0

bs
University

Mising
Employment Status

Emf,oye
5rudent
llousewife

02

3r8
6.9
52.0

tlm<mf,rye

4.7

Otler

4.4

Missing

Follow up consistently with doctor

Follovrup clinic

I38

02
60,0

Pl{JFomily

62

lvldicine

fulmonary
lnteflvl Mdicite

&lw
llo dhw-up

r0.2

t8

la
,{OO

No education about asthma

5r.6

fto education about rYledication

&-7

(devices)
ED

visis

<3

613

>?

36-7

Missing
Asthma control

20

UncontrdH

23i

Poftially

74.4

antalld

tN perwp

Complet*
antrol

l8

Missing

05

tutttdrd to olrc derit pL

The asthma-related ED visits were classilied on the

basis of whether the asthma patient had three or more

asthma-related ED visits. Table 3, shows the relationships between three or more astluna-related ED visits
and the patient's education level, education about
asthma, ISC, and asthma control. Those who were not
educated about asthma lverr more likely to visit the ED
because of asthma than those who had been educated
about asthma (42.7% versus 31.5%, p-value =0.0145).
More of the patients with uncontrolled asthrna (ACT
score < 15) than pa*ially/fully controlled asthma (ACT
score > 15) made three or more ED visits (52.4% versus

32.9%, p-value =0.0003). Table 4, shows the relationships

ktween asthma control and patient's demographic and

clinical characteristics. There was a relationship between
patient believe of needing orygen for asthma therapy
and three or more ED visits (40.5% versus 28.2%,
p-value =0.S209), there was no relationship beh,seen vi$it

ED primarily to obtain a bronchodilator and three or

more ED visits (36.5% versus 43.3%, p-nalue =0.3081).
Mann-Whitney test revealed there uras no relationship
between the duration of the disease and the number of
ED visit (p = 0.3944). An education level higher than
high school {p-value=0.0071), an uncontrolled asthma
(p-value = 0.0063), and irregular follow up with clinics
(p-value = 0.0328) were highly associated with three or
more asthma-related ED visits, after being controlled
for gender, ICS use, ducation level, educati,on about
medication, and education about asthma (Table 5). As
found in this study, the patients with university education were twice more likely to visit the ED than the
patients $'ith high school or &ot educated (OR: 2.359;
95% CL 1.263, 4.N7). The patients with uncontrolled
asthma were twice as likely to ome to the ED compared
with the patients with controlled asthma (OR: 1.924;
95%"A: 1203, 3,O7n This study also showed that
asthma control as determined by ACT had a significant
relationship with ICS use (p-value = 0.0401), asthma education (praalue=0.0117), ED visit primarily to obtain a
bronchodilator (p-value = 0.0001), and ED visit to obtain
oqgen (p-value = 0"0203). The distribution of uncon-

trolled asthma varied depending on patient ICS use

Q7,6% irregular, while 19.4% regular use). Those who
had not been educated about asthma were more likely
to have uncontrolled asthma than those who had been
educated about asthma (28.1% versus 18.1%).

Dkcussion
While this study is not epidemiological, it is the first
study to investigate the factors leading to ED visits in a
sample of Sau& bronchial asthma population and the
characteristics of those patients. The major strength of

this study lies in direct interviewing the patients and

confumation of the information obaiaed by reviewing
the medical record- It is very important to examine these
factors, because, we observed that many patients depend
on the ED for asthma management. Ifuowing these factors may help address some of the deficiencies in our
health system. The national and international guidelines
for the management of bronchial asthma emphasise patient education and rqular follow up with asthrna professional. Our study generally showed that a substantial
number of patients do not follow up asthma Eranagement with physicians and did not reeeive any education
about asthma as a disease. A zubaantial number of our
patients also used ED as an easy way to access their

Al-Jahdali et aL BtiC tufuonary Mdkine 2012, 12f{)

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Page4o/.T

percentage of uacontrolled or partially controlled bronchial asthma (95%) among the patients in major tertiary
care hospitals [26]. The result of our study raises na-

Table 2 !&rowledge about asthma managcment and

Reasons

for visi$ng the ED (il =45O1

R@aforA)*tt

bronchodilator
Vlsit EO to obtain orygen

tbJ

Msit ED primarily to obtain a

The sorerity of asthrna

doent

allo! , the patient to wait for

75.1

2l.l

dinic visit
Belief that the patient is treated faster in the ED

'lhe

20.9

ED is available 24 hours a day

19.1

The patient treated directly without delay

20.9

Medication given as rbuliar at ED is more useful

r9.6

tltplxd@oooutd,,,nnl,ntrr,ryrut
Take bronchodilator torelieve symptoms only

873

Srop |cs therapy when feel better

8r.6

Beliele long term use of inhaler unsafe

427

Belisae continues use of inhaler cause

Believe asthma thenpy use

deperdence

35.1

is effect overtirne

403

synptoms
Does no kpur wtut *orlld do duing asthma attad

74J

Does not knoar what trigger asthma

rN

289

manno{,erumMloolcdedlrtlat.

asthma management instead of keeping a follow up appointrnent with asthma professionals. Thi$ is not trnique
for our population, and many studie have reportod the
same findings [14,f525]. The majority of our padents

exhibited uncontrolled or partially coatrolled bronchial

asthma t973%) in the months preceding the ED visii
which is unaccepably higtr. However, this result also
consistent with our previous finding of a substantial

tional concerns regarding our current asthma nranagemmt system, which requires better health delivery
struchrres, easy dinic access for ptients, better patient
education, better disseminatior of the current national
asthma guidelines and better monitoring. Asthma educators only educated 17% of tlre patients in this study; &is
was primarily due to the lack of trained asthma educators in many tertiary care hospitals and definitely contributes to the number of patients with uncontrolled
asthma and the number of ED visits. The maiority of
our patients who had follow up visits (40%) attended the
follow up at a primary care clinic, where the setting for
asthma education is not very strong. The lack of patients
education about asthma is obvious, as almost 4d)96 of our
patients were never taught how to use asthma devices.
Studies have shown that ensrring that asthma patients
undersand their medication and the appropriate use of
a drug delivery device contributes significantly to asthma
control ln40l. Furthermore, Hanania NA et aL [31]
have shown that many of the medical
responsible for instructing and educating patients in optimal
inhaler use lack rudimentary skills with these devices,
seldom receive formal training in the qse of inhalation
devices, and rnay be not familiar with newer inhalation
devices and techniques. We believe that our study identify probably a eubstantial problem in our tealth care
system, particularly in the primary care setting. Abudahish, A et al. t32l have shown that asthma management
in primary care is unsatishctory. Our study also revealed

Table 3 The assodation beturcen asdrma-trhited ED vtslti and demographk and

Vqffi
Crender

Regular lCS use

Follor up with clinics

Education le\el

Educated about asthma

> 3 vlshs

(n=l6|il

tiale

638

362

Fanok

6ra

38.2

Ya

65.6

*.4

,vo

596

40.4

Y6

61.4

386

lvo

ils

352

&a

3s2

4.4

516

HiTh

rcholwbs

Y6

645

355

,vo

60.r

39.9

Yes

68s

3t5

573

427

l,Jo

ACT

liort

contolld

fu ttiolty/Fuil controlld
rfi',r

characterisffcs {ll = 44t}

(n=276)

Uniwrsity
Educated about medication

dlnlal

< 3 viCts

A*{yaE tutifrc E slgnflf@/t t ot {re.ut,evdtAn

,g@/rtdge

mtffi a orc dgdm,/",

476

52.4

67.1

32,9

rd
0s721

0.r880

0.4688

0.0133r

03498

0.0145*

0.m3'

AL-Jahda[ f ar. BlttlC tulnanary iiedicine 2012, 12f,0

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Page 5 of 7

Table t[ The assodafon between ttre astbna cont]ol tst {lCT) and denrognphk and clinlcal draracurisdcs (N=4t8}
Lantt
P.rd.lly/full controlled (n = 343)
t{ot conmlled (n = t(lti)
ttd.n
Gender

Regular |CS use

Follow up with clinics

Education level

Educated about medication

Educated

aboutasthma

%tt|r,b

760

240

Fqnab

765

23.1

Y6

80.6

19.4

iio

72.4

27.6

Yes

n8

222

No

75.1

24.9

High xtrool or les

n2

228

Univeryity

72.1

279

Y6

785

21.4

,vo

744

26.0

Yes

8r.9

l8.t

IVo

71.9

2&l

T,|p(,,4{4d/d/re statisdrbsignlfunt otrtre

04220

0.0401*

05188

038s3

02650

0.01

lr

$5levdtff ,f,r',!tqe rwtd /od/v daintol.

the common misundersianding of using the ED to receive a nebulised bronchodilator and oxygen as primary

therapy for acute asthma among many of our patimts.

Approximately 803i of the patients were classified widr

mild asthma by the National Asthma Educating Program
(NAEAP), and tlrese patients would probably obtain relief from their symptoms by usrng rescue MDI broncho-

dilator without need to visit ED

if

they received the

appropriate education. rife also exarnined the factors

that lead to three or more ED visits over the preceding
year, believing that patients with frequent ED visits
probably have less control over their asthma. In our
study, the more educated patients reported three or
more ED visits; however, the nurnber of these patients
was generally small (13%), and most of them experienced moderat to severe asthma (data not shown).
Similar to ofher strdies investigating the lack of asthma
education, uncontrolled or pa*ially controlled asttuna
were major rasons for the ED visit, in addition to inconsistent clinic visits [15,16]. This study is only based
on two teaching hospitals in the central region of Saudi
Table 5 lhe oddi ratbs md 9t96 Cls for

tte

Arabia and may not reflect the situation at the national

level. However, we believe that this study reflects the
current general characteristics and risk factors for crisis
oriented care and dependence on the ED for the management of bronchial asthma exacerbations Furtherrncre, the situation rnay be even wo(se if we assessed
these data at the country level, where the infrastrucErre
for asthma management may be less well
Limitations

One of the major limita[ons of this study is the inability

to assess the components or Sualrty of the different
asthma education or iaformation prqtrrms our asthmatic patients received from health care professionals,
In addition, we did not examine the detailed risk factors
for astlma exace6ation, sueh as an environmental risk
for exacerhtions at home or in working environments.
The second limitation is the lack of an economic eyaluation for an ED visil While the Saudi Arabian govemment provides free health care for all Saudi citizens, we
could not readily assess the accessibility of outpatimt

rtsk factors assochted rridr

tirce or rnore as0rma-rehted

lntercept

424a7

03s2

Age

0.00344

rdsits

gli%cl

ofi
05984

r.003

0991

1016

Gerder

Female

0.0694

05r92

1.149

0.753

1152

Regular ICS use

No

0.0594

06348

1.126

0.690

ta38

ACT

Uncontrolled

03272

0.0063*

1924

1"203

3077

Follow up with clinics

No

427{6

0.0328r

o5n

0349

0.956

Eduotion lercl

Univeaity

0.4292

0.0071*

2359

1263

4.47

Eduoted about medication

No

0.0790

05844

1.171

0665

2M2

Educated about asthma

No

02u2

0.1506

1504

0862

252s

'WaA Ch*r$nE

tuffi

b ttgntficiltt ot d7.$ led.;

AL-Jahdali ef aL BMC tulnwnary Medicine

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Page 6 of 7

A8

clinics at both institutions, as it was not the aim of the

study. Another limitatioa is not comparing &e risk factors of our patients to thoe patients who attend outpatient clinics; howevef,, our prwious study found that
the majority of the patients at outpatient clinics stjll have
uncontolled asthma [26] and hold many false belie8
and misconceptions about bronchial asthma as a disase
and the role of inhaled corticosteroids and the frctors
affecting compliance among adult asthmatic patimts [33]"

Conclusion
Our study has identiffed serreral factors that increase rhe
risk of repeated ED visits for the crisis oriented care of
asthma. The major factors we identified are a lack of
asthma education, the lack of regular follow up with specialised asthma clinics, patient misunderstandings about
the role of EDs in the treatment of bronchial asthma,
and the underutilisation of inhaled steroid use. Most of
these factors can be addresed by heal*r care providers,
and health ere planners can recti& these problems by

Reiercnces

1.

2
3.
4.

fhara(2CfF,,55(n56-573.

5.
6
7.
8.

10

Compedng lntrertj

13.

l.

12

14.

JH: Rs/iew

collection form arxj draft the first manuscript AA: perform all statistical
analysis and writ the resuh section. HA: Supewising the data collection at
KAMC. SB:-Scientifically contribute to writing the proposal. HR Supervising
the data collection at KKUH. SA : Providing scientific expertise and
operational guidance to data coilection at f'Ai1C and actively gecipitaring in
contdbuting in tt manuscript writing as per assignment by Pl. M5:
ScientifiGlly contribute to writing the proposal and study conduc at KKUH.
All authors read and approved the final manuscript.

Author details
rDepartment
of Medicine, Pulrnonary DMsion-lCU, rcrg saud University for
Health kierres, Rrydh,Saud Aobia lDeprtntent cf Epidemiology ard
Biosutistics, College of Publ'r Health and l-hahh, lnformatict Xing Saud bin

AMulaziz University for Health kiencet R}adh, Saudi Anbia.3Asthma

Research Chair and Prince Naif Center for lmmunology Research,
Depatment of PaedUuis, C;ollege of illedicirc, Kqg Saud Unirrcrsity, Ripdh.
lHead
Saudi tuab&L
of Pulmonary Divisiorr lvledical Direcror of Sleep
Dsorders Center, AdJunct professor Mcclll Un[rerslty, XlrE Saud Unlver*y
for Health Science$ King AMulaziz Medical City, Ripdh, Riyadh, Saudi

'l

6.

mI2

37(3)252-254.
Aelony
tiYhy patients

wilfi ast'tma go to the

ernrgency room.

lni{n 1S0,243{8):732
Al Zabdl H, E Sharif N: Factss assochted with ftequsrt emergeno/
room attendance by asthma patients in Palesllne.lnt jTufutc LutE D:ts
Berkas BM, Bkcan A: Effecs of atrnospheric stdphw diodde and
particulate matter concentrations on eme,gncy rcorn admisiom due
to asthma in Ankan. Tufurk Torok 2A03, 5l(3)131-238.
Chugh K Acute asthma in emergency room. lndian J Pediotr 2fi3,

Tqsupd l):9&S33.

I ,I

Dalcin PT, Piovesan DM, K,ang

Femandes AK, Franciscatto E, Millan
ei
FactoB assoaiated with emergency departmert yisits dlE to aute
asthma. Braz J lkd &nl Res 2W,37(9)1331-1338.
Dales RE, khlreiuer I Ken P, Gougeon L RMngton R Draper J: Hsk faGors

recunent emergrenqy department visis for a$hrra liora( lgg5,

5q5)520-524.
Ford JG. lvlqnr lH, Stemfels P, Findley 5E, Itldean DE, Fagan j( a ol
Pattems and predictors of asfima-relatd emergency departrnent use in
tlarlern. Gresr ?001. 120(4):1 1 29-l 1 35.
Garrett Jf, Mulder J, WongToi H: Chancreristics of a:*rmatics using an
urban accidem and emergency departmer& NZrtedl 191]8.

ft

11359-36r.

Flanania NA, David-l$/ang A, Kesten S, ChapEnan XR: Factors arsociated

with emergency depatment dependence d patients with asthma

Chett I $L I I !{2)290-29t
Lee PY Xhoo EM: Hor well uere asthmatic patien8 educated abort their
asthma? A

rtu* a the enrergency

depafinenl"-

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Received 27 No\rember 2012 A(epted: 14 Deember

Published: 17 Decembs 2012

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Adooude&mentt
We would like to thank Dr. Ali Al{arhan and Dr. Raeied Hejaze for facil;tating
our access to the EDs and helping identiry potential patients. We also thank
King Abdullah lntemational Medical Research Center ((AIMRO for funding
and provide editing supponing this research.

the Unied Sates. N

fu

The authors declar that they have no competing interests.

the scientific literature pertinent to the research question. W.iting

the proposal and responding to rev'ewer and IRB comments. Caeate data

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