The Journal of Pediatrics
Volume 154, Issue 6 , Pages 786-788, June 2009

Seventeen Years of Asthma Guidelines: Why Hasn't the Outcome Improved for Children?

  • Miles Weinberger, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Miles Weinberger, MD, Pediatric Department, UIHC, 200 Hawkins Dr, Iowa City, IA 52242

Pediatric Allergy & Pulmonary Division, UIHC, Iowa City, IA

Received 19 October 2008; received in revised form 8 December 2008; accepted 6 January 2009.

Article Outline

Abbreviations: EPR, Expert Panel Report, NAEPP, National Asthma Education and Prevention Program

 

Practice guidelines for asthma by the National Asthma Education and Prevention Program (NAEPP) administered and coordinated by the National Heart Lung and Blood Institute of the National Institutes of Health have been published in Expert Panel Reports (EPR) beginning in 1991, with updates in 1997 and 2002.1, 2, 3 Despite the considerable efforts and ambitious goal of the Expert Panel to improve asthma outcome, a report in 2006 from the National Center for Health Statistics concluded, “The most current data show that the challenges of childhood asthma remain and that asthma persists as a significant public health problem.”4 A 415-page EPR3 with a 60-page summary was released in 2007.5, 6

See editorial, p 784 and related article, p 789

Is that extensive latest revision of the Guidelines likely to improve outcomes for children with asthma more than the previous efforts? There is evidence that applying guidelines in clinical practice has not been highly successful.7, 8 Certainly, examination of available data do not support a positive impact for improving asthma outcomes in the U.S pediatric population at large. Neither hospitalizations, emergency department visits, nor deaths have decreased in children since the inception of the Guidelines in 1991 (Figure 1, Figure 2, Figure 3).4 Because younger children, particularly, have had the highest rate of hospitalization for asthma,9 and asthma most frequently has its onset during the early years,10 these data4 indicate that this 16-year effort to improve asthma outcome in children has thus far been ineffective. This lack of improvement in hospitalizations, emergency care, and fatalities cannot be argued to result from increased asthma prevalence during this period because the reported increase appears to be confined to identification of children with mild symptoms.11, 12

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Application of the Guidelines 

There are several reasons that can be suggested for the paradox of 16 years of authoritative guidelines and the absence of apparent benefit for children with asthma.9 First is the problem of implementing the guidelines in primary care, where most children with asthma receive care.13 A second and related problem is the length and complexity of the EPR, which inhibits effective integration into primary care practice.

Acknowledging that the efficacy of the EPR Guidelines had not been demonstrated to reduce asthma morbidity and hospitalizations when used in primary care, Cloutier et al14 developed a simplified application that focused on diagnosis, assessment of severity, appropriate prescribing, and development of a written action plan. They introduced this in 6 primary care urban clinics in Hartford, Connecticut, 4 of which were part of the University of Connecticut Health Center pediatric or family medicine residency programs. The results included an overall decrease of 35% in hospitalizations and 27% in emergency department visits. Although those results were statistically significant and clinically important, an accompanying editorial pointed out that even after 3 years, only about half of the children likely to have asthma had been enrolled, and this demonstrated a reliability for health care delivery of approximately 50%.15

Other clinical trials to improve primary care of asthma have demonstrated less benefit than the Cloutier study. The National Cooperative Inner-City Asthma Study used masters-level social workers as asthma counselors in a randomized study designed to improve asthma care.16 Even though a very modest although statistically significant decrease in symptom days was observed, there were no significant decreases in hospitalizations or unscheduled medical care visits. In a study involving 74 general practice pediatricians who were randomly assigned to an interactive seminar, improvements in process and outcome did not include any overall decrease in emergency department visits or hospitalization for asthma when comparing the physicians assigned to the seminar group compared with control subjects.17 Similarly, a randomized trial of 101 primary care providers assigned physicians to a program called PACE (Physician Asthma Care Education) or a control group.18 The outcome of asthma at the sites that received the program included some measurable clinical benefit but no decrease in hospitalizations or urgent office visits. Although that report did indicate a greater decrease in emergency department visits for patients of those who participated in the PACE program compared with the control subjects, the actual number of emergency department visits during the year subsequent to the program were similar between the control group and those in the program.

Several specialist-guided and team-directed model programs involving selected primary care physicians have been shown to impact positively on outcome of asthma in children.19, 20, 21 However, the greatest degree of effectiveness for asthma management has been documented for care programs directed by subspecialists that utilized continuity of care, an organized plan for effective therapeutic decisions, and patient education to carry out the plan.22, 23, 24, 25, 26, 27 In a report of a 1-year outcome of adults admitted to a health service hospital in the United Kingdom by either a general medical physician or a respiratory disease specialist, all symptoms were less during the year after admission for those admitted by the respiratory specialist. The rehospitalization rate was 20% for those admitted to the general service and 2% for those initially admitted to the respiratory service.24 Even among particularly difficult groups of patients where socioeconomic factors complicate care, randomized controlled clinical trials have demonstrated that specialized programs substantially improve outcome.25, 27 In one study adults who had previously required multiple hospitalizations for asthma were randomized to an intensive outpatient treatment clinic, or to their usual clinic at the same inner city hospital. A 3-fold difference in subsequent readmission rate was observed in favor of those in the special treatment group.25 In a study of children enrolled in Medicaid with high frequency use of emergency medical care services for asthma, randomization to the pediatric allergy clinic or the general clinic at the same children's hospital was associated with a reduction of hospitalization to about one third that of the previous year in those randomized to the allergy clinic, whereas little decrease occurred in those who continued to receive their care from the general clinic.27 Two of the studies demonstrating improved outcome from respiratory disease specialists were published before the Expert Panel Reports.24, 25

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What Should Be Done? 

Since the success of asthma care in specialty programs demonstrates the feasibility of improving outcome, an argument can be made that high-risk patients, that is, those who have had a previous history of recurrent urgent care or hospitalizations, should have their subsequent care managed by an asthma care program with a demonstrable track record for successful outcomes. Such programs can be directed by any physician, specialist, or generalist, with an interest and experience in managing asthma. It is not specialty training so much as experience and commitment to excellence and quality improvement in care that is most likely to improve outcome.

Perhaps use of a pay-for-performance compensation plan that provides financial rewards for avoiding hospitalizations and urgent care requirements should be considered. However, upgrading the knowledge, skills, and experience of primary care physicians is essential for improving asthma outcome on a national level. Although asthma is the leading inpatient diagnosis at most pediatric training programs,28 there is frequently no required systematic exposure to successful subspecialty-directed ambulatory asthma management.

Books, journal articles, and continuing medical education programs regarding asthma are available, in addition to the NAEPP Guidelines. However, although didactic material disseminates information and potentially improves cognitive knowledge, it has often been shown to do little to actually influence decision-making and behavior in the assessment or management of a clinical problem.29

To better address the national failure to improve the outcome of asthma in children, I propose that all institutions with pediatric residency programs have a specialty-based asthma management program in which all residents participate at some time during their training. Current requirements for pediatric residency include minimum standards for intensive care (neonatal and pediatric intensive care unit), adolescent medicine, developmental/behavioral pediatrics, and a minimum of 7 months in subspecialty rotations that can include but do not mandate allergy/immunology or pulmonology. Mandating that at least a month's rotation be spent experiencing specialized care for ambulatory children with asthma would likely have the eventual impact of improving the care of asthma because those residents subsequently go into practice or become involved in teaching general pediatrics. A simplified base of patient-oriented evidence that covers the essentials can be extracted from the complex compendium of the NAEPP Guidelines as the pedagogical basis for such a program.30

The Pediatric Residency Review Committee of the ACGME should address this frequently unmet educational need by mandating that such a specialty-based care and teaching program be in place, just as they require other programs such as a neonatal and pediatric intensive care unit for certification of pediatric training programs. We should do no less for this leading cause of hospitalization for children.

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References 

  1. National Asthma Education Program Expert Panel Report (Guidelines for the diagnosis and management of asthma). National Heart, Lung, and Blood Institute, National Institutes of Health; 1991;Publication No. 91-3042
  2. National Asthma Education Program Expert Panel Report 2 (Guidelines for the diagnosis and management of asthma). National Heart, Lung, and Blood Institute, National Institutes of Health; 1997;Publication No. 97-4051
  3. National Asthma Education Program Updates on Selected Topics from Expert Panel Report 2. Guidelines for the Diagnosis and Management of Asthma, National Heart, Lung, and Blood Institute, National Institutes of Health. 2002;Publication No. 02-5074
  4. Akinbami LJ. The State of Cchildhood Asthma, United States, 1980-2005. Advance Data for Vital and Health Statistics, No. 381, CDC. December 12, 2006;http://www.cdc.gov/nchs/data/ad/ad381.pdf
  5. National Asthma Education Program Expert Panel Report 3 (Guidelines for the diagnosis and management of asthma). National Heart, Lung, and Blood Institute, National Institutes of Health; 1991;http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
  6. National Asthma Education Program Expert Panel Report 3, Summary Report Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute, National Institutes of Health; 2007;NIH Publication Number 08-5846
  7. Taylor DM, Auble TE, Calhoun WJ, Mosesso VN, Mosesso VN. Current outpatient management of asthma shows poor compliance with International Consensus Guidelines. Chest. 1999;116:1638–1645
  8. Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000;154:685–693
  9. Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics. 2002;110:315–322
  10. Yunginger JW, Reed CE, O'Connell EJ, Melton LJ, O'Fallon WM, Silverstein MD. A community-based study of the epidemiology of asthma (Incidence rates, 1964-1983). Am Rev Respir Dis. 1992;146:888–894
  11. Kwong GNM, Proctor A, Billings C, Duggan R, Das C, Whyte MKB, et al. Increasing prevalence of asthma diagnosis and symptoms in children is confined to mild symptoms. Thorax. 2001;56:312–314
  12. Anderson HR, Ruggles R, Strachan DP, Austin JB, Burr M, Jeffs D, et al. Trends in prevalence of symptoms of asthma, hay fever, and eczema in 12-14 year olds in the British Isles, 1995-2002: questionnaire survey. BMJ. 2004;328:1052–1053
  13. Partridge MR, Fabbri LM, Chung KF. Delivering effective asthma care—how do we implement asthma guidelines?. Eur Respir J. 2000;15:235–237
  14. Clouter MM, Hall CB, Wakefield DB, Baut H. Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children. J Pediatr. 2005;146:592–597
  15. Muething SE, Kotagel U. Reliability of the health care delivery system. J Pediatr. 2005;146:581–582
  16. Evans R, Gergen PJ, Mitchell H, Kattan M, Kercsmar C, Crain E, et al. A randomized clinical trial to reduce asthma morbidity among inner-city children: Results of the National Corporative Inner-City Asthma Study. J Pediatr. 1999;135:332–338
  17. Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101:831–836
  18. Cabana MD, Slish KK, Evans D, Mellins RB, Brown RW, Lin X, et al. Impact of physician asthma care education on patient outcomes. Pediatrics. 2006;117:2149–2157
  19. Cloutier MM, Wakefield DB, Sangeloty-Higgins PS, Delaronde S, Hall CM. Asthma guideline use by pediatricians in private practices and asthma morbidity. Pediatrics. 2006;118:1880–1887
  20. Guarnaccia S, Lombardi A, Gaffurini A, Chiarini M, Domenighini S, D'Agata E, et al. Application and implementation of the GINA asthma guidelines by specialist and primary care physicians: a longitudinal follow-up study on 264 children. Prim Care Respir J. 2007;16:357–362
  21. Fox P, Porter PG, Lob SH, Boer JH, Rocha DA, Adelson JW. Improving asthma-related health outcomes among low-income, multiethnic school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies. Pediatrics. 2007;120:e902–e911
  22. Fireman P, Friday GA, Gira GC, Vierthaler WA, Michaels L. Teaching self-management skills to asthmatic children and their parents in an ambulatory care setting. Pediatrics. 1981;68:341–348
  23. Najada A, Abu-Hasan M, Weinberger M. Outcome of asthma in children and adolescents at a specialty based care program. Ann Allergy Asthma Immunol. 2001;87:335–343
  24. Bucknall CE, Robertson C, Moran F, Stevenson RD. Differences in hospital asthma management. Lancet. 1988;1:748–750
  25. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med. 1990;112:864–871
  26. Kelso TM, Abou-Shala N, Heilker BM, Arheart KL, Portner TS, Self TH. Comprehensive long-term management program for asthma: effect on outcomes in adult African-Americans. Am J Med Sci. 1996;311:272–280
  27. Kelly CS, Morrow AL, Shults J, Nakas N, Strope G, Adelman RD. Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in Medicaid. Pediatrics. 2000;105:1029–1035
  28. Jennings RM, Thompson LA, Townsend CL, Stashwick CA, Goodman DC. The relationship between pediatric residency program size and inpatient illness severity and diversity. Arch Pediatr Adolesc Med. 2003;157:676–680
  29. Mansouri M, Lockyer J. A meta-analysis of continuing medical education effectiveness. Journal of Continuing Education in the Health Professions. 2007;27;:6–15
  30. Weinberger M. Pediatric Asthma and Related Allergic and Non-Allergic Diseases: Patient-Oriented Evidence Based Essentials that Matter. Pediatric Health. 2008;2:631–650

 The author declares no external funding or conflicts of interest.

PII: S0022-3476(09)00007-9

doi:10.1016/j.jpeds.2009.01.003

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    H. James Brown, Paul V. Miles
    The Journal of Pediatrics June 2009 (Vol. 154, Issue 6, Pages 784-785)

  • Factors Associated with Variability in Outcomes for Children Hospitalized with Urinary Tract Infection , 26 March 2009

    Patrick H. Conway, Ron Keren
    The Journal of Pediatrics June 2009 (Vol. 154, Issue 6, Pages 789-796)

The Journal of Pediatrics
Volume 154, Issue 6 , Pages 786-788, June 2009

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