A randomized trial of primary care provider prompting to enhance preventive asthma therapy
Article Outline
Halterman JS, McConnochie KM, Conn KM, Yoos HL, Callahan PM, Neely TL, et al. Arch Pediatr Adolesc Med 2005;159:422-7
Context Urban children often receive inadequate therapy for asthma. One reason may be that primary care providers are unaware of the severity of their patients’ symptoms.
Objective To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to prescribe a new preventive medication or modify a current dose.
Design Randomized controlled trial.
Setting Rochester, New York.
Participants Children age 3 to 7 years with mild persistent to severe persistent asthma.
Interventions Children were assigned randomly to a provider notification group (child's primary care provider notified of asthma severity) or a control group (provider not notified of asthma severity). Primary care providers of children in the intervention group were sent a facsimile indicating the child's symptoms and recommending medication action based on national criteria. Interviewers blinded to the child's group assignment called parents 3 to 6 months later to determine whether preventive actions had been taken.
Main Outcome Measures Number of children who received a preventive medication action.
Results Of 164 eligible children, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P = .57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P = .85), recommending environmental modifications (39.3% vs 42.4%; P = .86), and making referrals for specialty care (6.6% vs 6.0%; P = .99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms.
Conclusions School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification did not improve preventive care, however. The findings suggest that more powerful interventions are needed to make systematic asthma screening effective.
Comment There is a gap between the asthma symptoms reported by families and appropriate physician treatment.1 School-based screenings can potentially be an efficient method to monitor symptoms of those children known to have asthma, as well as to identify new cases. This study suggests that feedback from a school-based screening delivered by facsimile is unlikely to prompt physicians to prescribe an asthma-control medication. Research suggests that when delivering feedback, the timing of the receipt of information (the facsimile) in relation to the intended action (initiating or changing a medication regimen) is associated with the success of the intervention.2 The physicians received the facsimile when the patients were not present in the office, and they may have preferred to initiate treatment with a patient present.
In addition, there are many barriers to prescribing daily medications for persistent asthma, including physicians’ unfamiliarity with the guidelines, concerns about adverse effects, and physicians’ beliefs that families may not adhere to such medication regimens.3 Although the results were negative, this study suggests that combinations of interventions may be needed to address issues with prescription of appropriate medications to treat asthma.
References
- . How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations?. Pediatrics. 1999;103:422–427
- . The modification of physician practice patterns. Clin Perform Qual Health Care. 1997;5:202–207
- . Reasons for pediatrician nonadherence to asthma practice guidelines. Arch Pediatr Adolesc Med. 2001;155:1057–1062
PII: S0022-3476(05)00820-6
doi:10.1016/j.jpeds.2005.08.053
© 2005 Elsevier Inc. All rights reserved.
