title: Missed opportunities to transition from nebulizers to inhalers during hospitalization for acute asthma: A multicenter observational study.
abstract: OBJECTIVE
  Hospitalizations for acute asthma are thought to be highly preventable through the use of efficacious medications, though many patients have poor metered-dose inhaler (MDI) techniques, thus lessening these medications' real-world effectiveness. Teaching MDI techniques during hospitalization may therefore lead to improved outcomes. However, MDIs may be underutilized to deliver short-acting β-agonists (SABAs) in the inpatient setting, despite equivalent efficacy to nebulizer delivery. We sought to characterize delivery methods of SABAs among hospitalized patients with acute asthma to understand if there are missed opportunities for self-management education.
  
  
  METHODS
  In this secondary analysis of a cross-sectional 25-center chart review study of children and adults (ages 2-54 years) hospitalized for acute asthma across 18 states (2012-2013), we studied SABA therapy delivery methods during hospitalization and receipt of action plans and follow-up visits. Unadjusted associations were analyzed using chi-square, Fisher's exact, or Kruskal-Wallis tests.
  
  
  RESULTS
  Of 987 patients, 44% received only nebulizer-SABA (children 32% vs. adults 53%; p < 0.001) during hospitalization, and 55% (children 68% vs. adults 47%; p < 0.001) received any MDI-SABA during hospitalization. Children receiving only nebulizer- vs. MDI-SABA were significantly less likely to receive individualized action plans (p < 0.001). Compared to children, adults were overall less likely to receive written plans (47% vs. 78%, p < 0.001) or to have a follow-up appointment (38% vs. 59%, p < 0.001) at discharge.
  
  
  CONCLUSIONS
  Opportunities exist to increase the delivery of MDI-SABA during hospitalization, particularly for adult inpatients with asthma. Further studies are needed to determine if increased use of MDI-delivered therapies improves patient education and outcomes.
authors.affiliation: a Department of Medicine , University of Chicago Medicine , Chicago , IL , USA.
authors.forename: Valerie G
authors.initials: VG
authors.lastname: Press
authors.affiliation: b Department of Emergency Medicine , Harvard Medical School, Massachusetts General Hospital , Boston , MA , USA.
authors.forename: Kohei
authors.initials: K
authors.lastname: Hasegawa
authors.affiliation: c Department of Emergency Medicine , University of Missouri Hospitals and Clinics , Columbia , MO , USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Heidt
authors.affiliation: b Department of Emergency Medicine , Harvard Medical School, Massachusetts General Hospital , Boston , MA , USA.
authors.forename: Jane C
authors.initials: JC
authors.lastname: Bittner
authors.affiliation: b Department of Emergency Medicine , Harvard Medical School, Massachusetts General Hospital , Boston , MA , USA.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D000208:Acute Disease; D000280:Administration, Inhalation; D000293:Adolescent; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage*; D000328:Adult; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D036501:Metered Dose Inhalers; D008875:Middle Aged; D055815:Young Adult
chemical_list: D000318:Adrenergic beta-Agonists
keywords: Acute asthma; asthma exacerbation; hospitalization; metered-dose inhaler; nebulizer; practice variation; short-acting β-agonist