The findings from this meta-analysis suggest that, relative to usual care, pediatric asthma education is associated with reductions in mean number of hospitalizations and ED visits and a trend toward decreased odds of an ED visit for asthma but does not affect odds of hospitalization or mean number of urgent physician visits. Findings from studies that compared 2 or more asthma education interventions suggest that interventions that involve more sessions and provide more opportunities for interaction between educators and children or care-givers may be more effective.
Why might asthma education affect the numbers of hospitalizations and ED visits but not the numbers of urgent physician visits? We believe this paradoxical finding may reflect the impact of asthma education on care-seeking behavior. In the studies we reviewed, children and caregivers who received asthma education may have been more aware of the importance of monitoring symptoms closely and may have promptly sought treatment from children's office-based providers if children experienced symptoms. Obtaining office-based urgent care before symptoms became severe may have obviated the need for ED visits and hospitalizations.
Changes in care-seeking behavior may also explain why asthma education had a greater effect on mean number of hospitalizations than on mean number of ED visits. Asthma education may have reduced the severity of exacerbations or prompted parents to bring children to the ED before their symptoms became very severe, which may have reduced the number of children who presented to the ED and required hospitalization. Alternately, some ED visits may have been unavoidable. Some visits may have been made on nights and weekends when children's office-based providers were not available. In other cases, children may not have had a usual source of asthma care and relied on EDs for treatment.
The presence of heterogeneity suggests that pooling results across studies may obscure important, systematic differences among the interventions and populations studied. Several explanations seem plausible. Educational interventions that address all 4 topics recommended in the NHLBI guideline might be more effective, because they are more comprehensive. Interventions composed of more or longer sessions may have greater impact, because educators have more opportunities to reiterate their messages. Individual education might be more effective than group education, because individual sessions can be tailored to the needs of individual children and caregivers. Similarly, educators in clinical settings may have access to medical charts that can enable them to customize content on the basis of a child's medical history, medication regimen, and/or allergy-test results. Differences in results might also reflect variation in rates of hospitalization and ED visits for asthma across regions, health systems, and types of health insurance. Unfortunately, the numbers of studies that evaluated each outcome were too small to permit quantitative analysis of subgroups of studies. We could only make qualitative comparisons. Those comparisons suggested that the interventions with the most favorable results tended to furnish comprehensive education to individual children or families in clinical settings.12,22,24,28,32,41,46
Previous meta-analyses of the effects of pediatric asthma education on ED visits and hospitalizations have reached different conclusions. These meta-analyses found that asthma education was associated with a statistically significant reduction in mean number of ED visits but had no effect on mean number of hospitalizations.3-6
However, our findings are not directly comparable because of differences in inclusion criteria. Whereas our meta-analysis was limited to studies conducted in the United States, the previous meta-analyses also included studies conducted in other developed countries. In addition, previous meta-analyses combined studies that compared asthma education to usual care with studies that compared 2 different asthma education interventions.