Reducing Emergency Department Use for Pediatric Asthma Exacerbations: A Feedback Approach

Background and Purpose:  Asthma is the leading cause of hospitalization for children in the state of Missouri. If it is not managed, it can be life threatening.  Emergency department (ED) visits and hospitalizations for asthma exacerbations that could have been prevented or managed put a strain hospital resources, create stress for families, and take a toll of children’s school attendance and academic performance.  In St. Louis where the estimated prevalence for childhood asthma is nearly twice the national average, several efforts from different sectors around the city have been made to help children manage their asthma and reduce ED use for pediatric asthma exacerbations, but ED visit rate remains staggeringly high, far surpassing the state and national ED usage rates.

This project describes insights gained about the drivers of the problem of high ED use rates for pediatric asthma through the use of a system dynamics computer simulation model.

Methods: This project uses a system dynamics approach, which is defined as method that draws on both qualitative maps/diagrams and formal computer simulation to understand complex problems from feedback perspective (Richardson, 2011). Data generated from four group model building sessions with 9-15 participants in each, representing diverse stakeholder groups including medical professionals, hospital referral coordinators, social workers, researchers and teachers, informed the initial construction of a system dynamics computer simulation model.   Additional data from the most recent asthma data from Missouri Department of Health and Human Services Behavioral Health Survey was also used to for St. Louis specific data on ED visits and trends over time.

Findings:  The computer simulation model was able to reproduce a feared behavior pattern of persistently high ED use rates with some increases in asthma management after public awareness of children’s deaths related to asthma. While in the short term, many of the policies and programs already in place are having little effect in reducing ED use and increasing asthma management, model results indicate that current efforts to educate children now, could improve asthma management in the next several years as these children grow to be adults.

Conclusions & Implications:  The drivers of ED use for pediatric asthma exacerbations are complex and embedded in feedback loops that create barriers for effective intervention.  Asthma education for children can have a strong effect on how childhood asthma is managed in the future, although initial returns may be slow to notice.   Qualitative maps and small simulation models can help public health professionals gain new insight into how their work fits with others and how it can contribute to achieving long term goals for healthier children.