Effectiveness of Nurse-Led Asthma Education Programs on Pediatric Emergency Department Visits

Introduction

Asthma remains one of the most common chronic conditions of childhood and a leading cause of pediatric emergency department (ED) utilization, with a substantial proportion of asthma-related ED visits considered potentially preventable through improved outpatient self-management (National Asthma Education and Prevention Program, 2007). Clinical practice guidelines consistently identify structured self-management education, encompassing trigger avoidance, correct inhaler and spacer technique, and use of a written asthma action plan, as a core, guideline-recommended component of pediatric asthma care, alongside appropriate pharmacologic management (National Asthma Education and Prevention Program, 2007; Sockrider et al., 2006).

A substantial body of prior research has evaluated the effect of asthma self-management education on outcomes including ED utilization and hospitalization, with meta-analytic evidence generally supporting a beneficial effect of structured education relative to usual care (Guevara et al., 2003; Boyd et al., 2009). However, this literature has evaluated a heterogeneous range of program models, delivered variously by physicians, respiratory therapists, community health workers, and multidisciplinary teams, and comparatively fewer studies have specifically evaluated nurse-led delivery within routine primary care as a discrete, replicable program model, despite nurses’ frequent, guideline-endorsed involvement in asthma education delivery in practice (Horner, 2008; Bruzzese et al., 2011).

This distinction is practically important for health systems considering how to scale asthma self-management education, since nurse-led delivery within existing primary care visits may offer a more readily implementable and sustainable model than programs requiring additional specialized staff or separate community-based infrastructure, provided its effectiveness can be established specifically in this delivery format. The purpose of this study was to evaluate the effect of a structured, nurse-led asthma self-management education program, delivered within pediatric primary care using a teach-back-based coaching approach, on asthma-related ED visits, hospitalizations, and asthma control over a 12-month follow-up period, relative to usual care.

Methods

Design. This study used a prospective, quasi-experimental cohort design with a nonequivalent comparison group, in which the education program was implemented at a subset of clinics within a single health system while comparable clinics continued usual care, and outcomes were tracked prospectively over 12 months. This design was selected over individual randomization because the program was implemented as a clinic-level practice change, making individual-level randomization impractical, while a nonequivalent comparison group with baseline covariate adjustment allowed for a more rigorous effectiveness estimate than a single-group pre-post design alone.

Setting and participants. Participants were children aged 2 to 17 years with a diagnosis of persistent asthma, defined per National Asthma Education and Prevention Program severity classification, enrolled from six pediatric primary care clinics within a single health system between January and June 2025. Three clinics had implemented the nurse-led education program as a standard practice change; three comparable clinics, matched on patient volume and general demographic profile, continued usual asthma care without the structured program. Children with a concurrent diagnosis of a different chronic respiratory condition, such as cystic fibrosis, were excluded. Of 431 eligible children approached across all six clinics, 384 were enrolled (196 program group, 188 usual care group; 89.1% enrollment rate).

Intervention. The nurse-led education program consisted of three structured, individual coaching sessions delivered by clinic nurses trained in a standardized teach-back protocol, occurring at enrollment and at four and eight weeks. Sessions addressed identification and avoidance of individual asthma triggers, demonstration and teach-back verification of correct inhaler and spacer technique, and collaborative development of a written, individualized asthma action plan specifying daily management and step-up actions for worsening symptoms. A brief telephone check-in was conducted at 12 weeks to reinforce action plan use.

Comparison condition. Children in the usual care group received standard asthma management at their primary care clinic, including physician-directed medication management and general verbal guidance regarding asthma control, without the structured, nurse-delivered teach-back education sessions or standardized written action plan development process used in the program condition.

Outcome measures. The primary outcome was the rate of asthma-related ED visits per patient-year over the 12-month follow-up period, ascertained through health system electronic health record review and caregiver report, with cross-verification for visits occurring outside the health system. Secondary outcomes included asthma-related hospitalization rate, rate of oral corticosteroid bursts, time to first asthma-related ED visit, Asthma Control Test score (range 0–27, or the age-appropriate childhood version), and caregiver asthma knowledge, assessed using a validated 20-item knowledge questionnaire, at baseline and 12 months.

Statistical analysis. Because assignment to program or usual care occurred at the clinic level rather than through individual randomization, inverse probability of treatment weighting, derived from a propensity score model incorporating baseline asthma severity, prior-year ED utilization, age, and insurance status, was used to address observed baseline differences between groups. The primary outcome was analyzed using weighted negative binomial regression, adjusted for baseline asthma severity, prior-year ED utilization, and clinic site, yielding an adjusted incidence rate ratio (IRR). Time to first asthma-related ED visit was analyzed using Kaplan-Meier estimation and compared using the log-rank test. Change in Asthma Control Test and caregiver knowledge scores was analyzed using analysis of covariance adjusted for baseline score. A two-sided p value of less than .05 was considered statistically significant.

Results

A total of 384 children were enrolled, 196 in the nurse-led education program group and 188 in the usual care comparison group (Table 1). Baseline asthma severity distribution and prior-year ED utilization were reasonably balanced between groups, though the program group had a modestly higher proportion of mild persistent classification and modestly higher prior-year ED use; inverse probability of treatment weighting was applied to address these and other observed baseline differences. Retention at 12 months was 92.9% in the program group and 90.4% in the usual care group.

Over the 12-month follow-up period, the program group had a significantly lower adjusted rate of asthma-related ED visits than the usual care group (0.41 vs. 0.79 visits per patient-year; adjusted IRR 0.52, 95% CI 0.40–0.68, p < .001), corresponding to a 48% relative reduction in ED visit rate. As shown in Figure 1, time to first asthma-related ED visit was also significantly longer in the program group (log-rank p < .001).

Secondary outcomes evaluating acute care utilization showed a consistent pattern favoring the program group, as summarized in Figure 2. Asthma-related hospitalization rate was significantly lower in the program group (adjusted IRR 0.46, 95% CI 0.29–0.73, p = .001), as was the rate of oral corticosteroid bursts (adjusted IRR 0.61, 95% CI 0.48–0.77, p < .001).

Asthma Control Test scores improved significantly more in the program group, from a mean of 17.8 at baseline to 23.6 at 12 months, compared with an improvement from 18.1 to 20.1 in the usual care group (adjusted between-group difference 3.3 points, 95% CI 2.5–4.1, p < .001). Caregiver asthma knowledge scores showed a similarly larger improvement in the program group, as shown in Figure 3.

Discussion

This prospective, quasi-experimental cohort study found that a structured, nurse-led asthma self-management education program delivered within pediatric primary care was associated with a significant and clinically meaningful reduction in asthma-related ED visits, hospitalizations, and oral corticosteroid use over 12 months, alongside improved asthma control and caregiver knowledge, relative to usual care. The 48% relative reduction in ED visit rate observed here is consistent in direction and comparable in magnitude to effects reported in prior meta-analyses of pediatric asthma self-management education across more heterogeneous program delivery models (Guevara et al., 2003; Boyd et al., 2009), extending this evidence base specifically to a nurse-led delivery format embedded within routine primary care visits.

The consistency of effect across ED visits, hospitalizations, and oral corticosteroid bursts, three related but distinct measures of acute asthma exacerbation severity, strengthens confidence that the observed association reflects genuine improvement in asthma control rather than a shift in care-seeking behavior alone, such as families in the program group simply being redirected toward primary care rather than experiencing genuinely fewer exacerbations. The parallel improvement in Asthma Control Test scores, a direct clinical measure of asthma control independent of utilization, further supports this interpretation.

The magnitude of improvement in caregiver knowledge scores, alongside the structured, teach-back-based design of the education sessions, is consistent with a substantial body of literature identifying teach-back verification as a mechanism for improving retention and correct application of self-management instructions, particularly regarding technical skills such as inhaler and spacer technique that are difficult to master from written instruction alone (Sockrider et al., 2006; Horner, 2008). This suggests that the specific pedagogical approach used, rather than education content alone, may be an important contributor to the magnitude of effect observed in this study.

Several limitations should be considered. Because assignment to program or usual care occurred at the clinic level rather than through individual-level randomization, residual confounding by unmeasured clinic-level or family-level factors cannot be entirely excluded despite the use of inverse probability of treatment weighting to address observed baseline differences; clinics adopting this program may have differed from comparison clinics in ways not fully captured by the covariates available for adjustment. The study was conducted within a single health system, and generalizability to health systems with different staffing models, patient populations, or baseline asthma care quality should be considered carefully. Finally, the 12-month follow-up period, while sufficient to detect a clinically meaningful reduction in acute care utilization, does not establish whether this benefit is sustained beyond the first year without continued programmatic reinforcement.

Future research should evaluate this program model using cluster-randomized designs where feasible to further strengthen causal inference, and should examine the durability of program effects beyond 12 months and whether periodic booster education sessions are needed to sustain the observed reduction in acute care utilization. Cost-effectiveness analysis incorporating the reduction in ED and hospitalization utilization documented here would further support health system decisions regarding program scale-up. Taken together, these findings support nurse-led, teach-back-based asthma self-management education as an effective and practically scalable component of pediatric primary care, capable of meaningfully reducing acute care utilization for a chronic condition that remains a leading cause of preventable pediatric ED visits.

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