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Fragmented care a risk for children with asthma: Study


Anastasia Tsirtsakis


15/02/2023 5:06:52 PM

Frequent GP visits improve health outcomes for children with asthma. But a lack of continuity of care is leading to higher hospitalisation rates.

A young boy laying in a hospital bed.
At just three years old, Ollie has been admitted to the emergency department 48 times for his asthma. Image: Supplied

For children with asthma, the evidence is clear – regular visits with a GP are vital to managing the condition and avoiding hospitalisation.
 
But, as it stands, not everyone has access to general practice care. Rachel Cornwell’s son Ollie is a prime example.
 
The three-year-old, diagnosed with severe asthma, has already been admitted to the emergency department (ED) 48 times. It is a 45-minute trip to the local hospital – one that Ms Cornwell says could be avoided if Ollie had access to a regular GP who was well-equipped to handle complex asthma cases.
 
‘Ollie doesn’t see a GP for his asthma because it’s an uphill battle to get an appointment and consistent care,’ she said.
 
‘He goes from 100 to zero in a flash. Day two of an asthma flare-up he would need to have IV treatment or oxygen in hospital. It is incredibly stressful to see your child struggling to breathe.
 
‘There was a point where we were going into the hospital fortnightly, and Ollie wasn’t receiving follow up care.’
 
Ms Cornwell says the GPs she has encountered have not been confident to treat Ollie because of his history.
 
‘You can’t predict when your child is going to have an asthma attack,’ she said.
 
‘So, you don’t have the luxury of booking an appointment in advance. It’s just easier and quicker to go to hospital.’
 
As the parent of a child with severe asthma, Ms Cornwell is not alone in her experiences.
 
The chronic condition is a leading cause of unplanned hospital admissions for children. In Victoria, readmission rates are on the rise, up from one in four children within 12 months a decade ago, to one in three.
 
New research led by the Murdoch Children’s Research Institute (MCRI) has found carers and children face a number of barriers that mean access to GP care is irregular and inconsistent.
 
Published in the Journal of Asthma and Archives of Diseases in Childhood, the studies involved 277 GPs and 767 caregivers of children aged 3–18 years who were admitted with asthma to one of three hospitals in Victoria between 2017–18.
 
The findings show that increased frequency of GP visits for children with asthma is associated with reduced ED presentations, hospital readmissions, and improved asthma outcomes. And yet, despite more than 90% of caregivers reporting that their child has a regular GP, only one in five children visited their regular GP on more than 60% of visits, 14.1% attended a GP in the 24 hours prior to index admission, and 35.8% saw a GP within seven days of being discharged from hospital for their asthma.
 
MCRI researcher Renee Jones said the findings highlight that children with asthma are receiving fragmented treatment in the primary care network.
 
‘Families often reported being unable to access primary care before presenting to a hospital for their child’s asthma, highlighting a potential missed opportunity for avoiding an admission and for continuity of treatment,’ she said.
 
Families also noted unclear pathways to follow-up care, with a lack of coordination between hospitals and their GP. The study shows only 39.2% of GPs said they knew their patient had been readmitted to hospital for asthma.
 
Ms Jones said the low rate of GP follow-up is worrisome given paediatric asthma care guidelines recommend children be reviewed after an ED presentation or hospital admission, as well as ongoing checks-ins.
 
Dr Kerry Hancock, Chair of RACGP Specific Interests Respiratory Medicine, told newsGP she is not surprised by the findings and says there is a need to better understand the flaws in the system.
 
‘The systems need to change so that GPs are automatically notified when their patient has been admitted to hospital and when they have been discharged,’ she said.
 
‘We need to find out why the system’s not working and why hospitals aren’t notifying practices. If they’re saying that they have notified them and they’ve done a clinical handover, we need to find out what the practices do with that information – are they not acting on it?
 
‘Is it that parents and carers have been informed that they should make an appointment to see their doctor within that week of discharge and they are not able to get appointments? Or are they not being made aware of the importance of the follow up with the GP?’
 
Dr Hancock says tackling the issue is ‘not rocket science’, but she does fear that barriers to care may have worsened post-pandemic and in the midst of the GP shortage.
 
With the RACGP broadly in favour of fully-funded voluntary patient enrolment, an idea proposed by the Federal Government’s Strengthening Medicare Taskforce, Dr Hancock says this is a scenario where it could prove effective.
 
‘If these families are attached to a practice, then that practice makes a commitment to providing ongoing care,’ she said.
 
‘We’ve done projects in metropolitan Adelaide focusing on that follow up of children who had been admitted to hospital … and connecting them with a general practice who would make a commitment to their ongoing care and be able to see them when they needed to be seen.’
 
The research also confirmed Ms Cornwell’s experience, with many of the GPs reporting that they lack confidence in managing paediatric asthma patients. Just 11.9% said they are ‘extremely confident’ managing children with poorly controlled asthma, 16.7% in managing children post-hospital discharge, while 36.4% said they were confident managing children with well-controlled asthma.
 
Dr Hancock says the numbers are low given how common paediatric asthma presentations are in general practice.
 
‘GPs should be competent and confident in managing asthma,’ she said. ‘But, admittedly, that percentage of children who have severe asthma, they may need some support to do that, such as from specialist colleagues.’
 
Since the studies were conducted, the Australian Asthma Handbook has been updated with additional information about the management of asthma in paediatric patients, which Dr Hancock says may help GPs ‘gain more confidence’ in managing the condition.
 
To ensure continuity of care, the RACGP is also advocating for patients to have additional support to see their GP within seven days of an unplanned hospital admission or ED presentation.
 
Dr Hancock said it cannot be underestimated how important follow up care is for anyone admitted to hospital – whether paediatric or adult patients – particularly for chronic conditions.
 
‘GPs are extremely busy, but we want to know if our patient’s been in hospital,’ she said.
 
‘We need to get the notification to say they’ve been discharged in a timely way – not two or three days later – we need to get it on that day, and it needs to become routine care.
 
‘Now it doesn’t have to necessarily be their usual GP, it could be somebody in their practice, and it could even be in a nurse-led asthma clinic. But there needs to be a connection with the practice and the practice needs to take ownership of that patient.’
 
Ms Cornwell’s son Ollie is now under the care of the Complex Asthma Service at The Royal Children’s Hospital and has seen improvements in his condition. She hopes greater awareness brings about change so other families can avoid the heartache.
 
‘The research could lead to much better care for children with severe asthma,’ Ms Cornwell said.
 
‘If we could see a regular GP who had the expertise to treat Ollie it would be a huge weight off our shoulders.’

Further information and support for patients and carers is available from Asthma Australia.
 
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