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The American Journal of Managed Care January 2016
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Effects of Continuity of Care on Emergency Department Utilization in Children With Asthma

Shu-Tzu Huang, MS; Shiao-Chi Wu, PhD; Yen-Ni Hung, PhD; and I-Po Lin, PhD
Better continuity of ambulatory asthma care can reduce the risk of asthma-related emergency department visits for children with asthma in Taiwan.
We found that children in Taiwan with newly diagnosed asthma generally had high continuity of ambulatory asthma care. The average COCI was 0.68 (± 0.31), while fully 42% of the patients had a COCI of 1, meaning they received all their asthma-related care from a single physician during the first year of observation. This high level of COC in Taiwan may be attributed to several factors. First, in addition to extensive insurance coverage and low co-payments for outpatient visits, Taiwan has no compulsory referral scheme or gatekeeper program, giving patients great freedom in choosing care providers. Second, the low birth rate and high level of education of parents allow them to focus on disease management for their children with chronic conditions like asthma. Third, the government began an asthma P4P program in 2001 based on a continuing care model, encouraging clinics and hospitals to provide patient-centered care focused on disease management, enforcement of follow-ups, and enhancement of patient self-care ability.

This study supports the results of Cree and Cyr et al.10,11 Higher continuity of ambulatory asthma care could lower the risk of using emergency care for children with asthma, with a trend of a dose-response effect. Hong et al studied COC in older adults in South Korea with 4 different chronic diseases, including asthma and diabetes, and found increased COC associated with a reduction in the risk of ED visits. This negative correlation was greater for asthma than for diabetes.12 In Taiwan, previous research on all patients and those with diabetes found that higher levels of COC could lower ED visits and hospital admissions.13,16,17 Thus, these findings support government programs like P4P to improve COC for patients with diabetes. Since our research showed that higher COC also had positive impacts on children with asthma, we believe this may help the government to plan programs to improve COC for patients with asthma in order to reduce the risk of ED visits.

With higher COC, patients and their physicians develop greater familiarity with each other as well as higher levels of trust. The physician can then more efficiently manage the medical conditions of returning patients, and patients are more likely to comply with instructions, subsequently leading to fewer asthma attacks. A previous study found that when providers designated someone to follow up with patients with asthma who were discharged from the ED, patients were more likely to have follow-up visits and had better quality of life, a care plan, and fewer asthma symptoms.23 Moreover, because Taiwan has very accessible healthcare, patients who trust their physician can substitute ambulatory care for ED visits. Christakis et al found no statistical correlation between COC and the risk of asthma-related ED visits in children with asthma in a health maintenance organization, but did find one for those with Medicaid.9 This finding supports the principle that universal insurance coverage and low co-payments of the NHI in Taiwan eliminate the economic barriers to high COC for children with asthma.

In terms of the number of asthma-related ED visits, we used the second component of hurdle regression, which focused on patients who had at least 1 asthma ED visit. All previous studies analyzed the number of asthma ED visits for all patients, including those with no ED visits. Cree et al found that high continuity of asthma care could decrease the number of asthma ED visits by 63%.10 In Canada, increasing the asthma COCI by 0.1 decreased the number of asthma-related ED visits by 19% for asthma patients aged 12 to 17 years.11 The 2-part hurdle regression reflects the sequential decision-making process for healthcare services. The response variable of the first part is whether to use the ED or not—a decision more likely to be decided by the patient and family, and thus, more likely correlated with personal characteristics. The response variable of the second part is the number or cost of visits, which is more likely to be associated with the characteristics of the healthcare system.24

Our research showed a significant correlation in the first part—that the continuity of ambulatory asthma care influenced whether newly diagnosed children with asthma in Taiwan went to the ED—but not in the second part, the number of asthma ED visits for users only. In most cases, inexperienced parents went to the ED when the first asthma attack happened; later, they were better able to control symptoms. Most of our patients who had at least 1 asthma ED visit went to the ED only once in the outcome period, which may have caused the statistical differences between COC groups to remain undetected.


Limitations and Strengths

The limitation to our study is common to secondary data analysis. The NHI database contains no information on the outcomes of medical examinations, so we were unable to directly measure the severity of asthma. Therefore, we controlled for the number of asthma outpatient visits,10,12,15,16,20 whether or not the patient made an asthma-related ED visit, and the total days of asthma hospitalization during the COC period, in order to diminish the effect of disease severity.

Our study has several advantages, however. First, selecting new patients as the study subjects helped avoid the effects of past disease history and care experience on later COC and medical use. Most previous studies included all patients, whether their asthma was ongoing or newly developed, except for a Korean study of patients aged 65 to 84 years with newly diagnosed asthma or other chronic diseases, and a Taiwanese study of the effect of COC on avoidable admission for patients with diabetes, which controlled for the effect of being a new patient.12,13 We chose new pediatric asthma patients as our study subjects to more specifically examine the relationship between COC and ED use. Second, using a longitudinal study design helped in determining the temporality of events. Van et al believed that COC and outcome may affect each other; worse outcome or low satisfaction may trigger the patient to seek the care of other physicians and further decrease COC.7 In this study, COC was measured in the first year and the outcome was measured in the second year, to construct clear temporality.

Third, using asthma outpatient visits instead of visits for all conditions to estimate COC can more accurately reflect the actual asthma care received. For instance, Chen and Cheng chose patients with diabetes to calculate the COCI for diabetes-related physician visits.16 They mentioned that, because of the lack of a compulsory referral system and the high number of outpatient visits in Taiwan, disease-specific COCI could more sensitively examine the relationship between COC and medical use. Therefore, in our study, only asthma-related outpatient visits were counted. Fourth, and finally, Van et al found that many factors influence the correlation between COC and outcomes, such as age and severity of disease, suggesting that these covariates should be controlled for.7 In our study, we included many covariates in the models to reduce the possible effect on our results of such factors as patient characteristics, enrollment in the P4P program, severity of disease, and care provider characteristics.

Our study showed that, for children with newly diagnosed asthma in Taiwan, better continuity of ambulatory asthma care could reduce the risk of asthma-related ED visits. We suggest that healthcare providers enhance follow-ups and self-care ability for high-risk patients with asthma with low COC. Also, we suggest that policy makers seek to develop effective ways for all children with asthma to maintain an ongoing relationship with their physician as a way to better control their disease.


The authors would like to thank the Ministry of Health and Welfare (project numbers: DOH099-TD-M-113-099016 and DOH101-TD-PH-15) and the Ministry of Science and Technology (project number: 103-2410-H-010-011-MY2) in Taiwan for providing the data set and financial support for this study.

Author Affiliations: Institute of Health and Welfare Policy, School of Medicine, National Yang Ming University (S-TH, S-CW, I-PL), Taipei, Taiwan, Republic of China; School of Gerontology Health Management, College of Nursing, Taipei Medical University (Y-NH), Taipei, Taiwan, Republic of China; Department of Health Care Administration, College of Management and Healthcare, Oriental Institute of Technology (I-PL), New Taipei City, Taiwan, Republic of China.

Source of Funding: This study was supported by grants (project numbers: DOH099-TD-M-113-099016, DOH101-TD-PH-15, and 103-2410-H-010-011-MY2) from the Ministry of Health and Welfare and the Ministry of Science and Technology in Taiwan.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (S-TH, S-CW, Y-NH, I-PL); acquisition of data (S-CW); analysis and interpretation of data (S-TH, S-CW, Y-NH, I-PL); drafting of the manuscript (S-TH); critical revision of the manuscript for important intellectual content (S-TH, S-CW, Y-NH); statistical analysis (S-TH); provision of patients or study materials (S-TH, S-CW); obtaining funding (S-CW); administrative, technical, or logistic support (S-TH, Y-NH, I-PL); and supervision (S-CW, Y-NH).

Address correspondence to: Shiao-Chi Wu, PhD, Institute of Health and Welfare Policy, School of Medicine, National Yang Ming University, No. 155, Sec 2, Linong S, Taipei, 112 Taiwan, Republic of China. E-mail:
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