Family Physicians Lead in Adhering to Asthma Guidelines

A study published this spring in the Annals of Allergy, Asthma & Immunology found that although physicians and other health care professionals have made headway in providing appropriate care for patients with asthma, some patients still are not getting the care recommended in national guidelines. In addition, the study found that subspecialty physicians have a 27 percent lower rate of prescribing inhaled corticosteroids to their patients with asthma compared with family physicians or general practitioners.

Study researchers tracked physician adherence to national asthma prescribing guidelines published by the National Asthma Education and Prevention Program, or NAEPP. In 1997, the NAEPP published the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, known as the EPR-2 guidelines. These guidelines stress the use of asthma pharmacotherapy in conjunction with environmental control measures to improve patient outcomes.

Specifically, the guidelines recommend using long-term controller medications (i.e., corticosteroids; mast cell stabilizers [cromones]; long-acting beta-agonists, or LABAs; long-acting methylxanthines; and leukotriene modifiers) to control asthma symptoms in patients with persistent asthma. The guidelines also recommend the use of short-term reliever medications (i.e., short-acting beta-agonists, or SABAs; anticholinergic agents; and systemic corticosteroids) to control acute exacerbations of asthma symptoms. Anti-inflammatory medications, such as corticosteroids, leukotriene modifiers and mast cell stabilizers, should be used to treat the underlying inflammatory processes, the guidelines note.

The EPR-2 guidelines also emphasize the key role physicians and other health care personnel play in providing good asthma education to their patients. Such education can help patients achieve better control of their asthma symptoms.

For this study, researchers performed a cross-sectional retrospective analysis of National Ambulatory Medical Care Survey physician visit data from 1998 through 2004. Overall, the study found that patients with asthma were 3.3 times more likely to be prescribed appropriate controller medications in 2002 than in 1998.

However, patients who self-identified as nonwhite and nonblack had a 40 percent lower chance of receiving controller medications than white or black patients. According to the researchers, this finding suggests that these nonwhite, nonblack patients are receiving suboptimal asthma pharmacotherapy.

Other results show ways in which physicians are using the guidelines in prescribing certain medications for patients who have asthma. Physicians prescribed LABAs 6.3 times more often in 2004 than in 1998, and they prescribed leukotriene modifiers 3.9 times more often than in 1998. In 2002, patients were three times more likely to receive a prescription for a combination of LABAs and inhaled corticosteroids than they were in 1998. Patients in 2004 were two times more likely to be prescribed a SABA than they were in 1998.

Perhaps the best news for FPs is that they are one of the groups most strongly promoting adherence to these guidelines. In fact, physicians who are not in primary care have a 27 percent lower rate of prescribing inhaled corticosteroids to their patients with asthma compared with family physicians or general practitioners.

"Family medicine is leading the way in adherence to the guidelines," said FP Kurtis Elward, M.D., the AAFP representative to the NAEPP Coordinating Committee and a member of the NAEPP's Guidelines Implementation Panel. In particular, family physicians seem to be doing better than other specialties in prescribing inhaled corticosteroids, he noted.

Elward pointed out that, according to the study, physicians who practice in a more organized atmosphere that has greater decision support tend to adhere better to the guidelines. That could explain why the message promoted by these guidelines tends to reach certain groups of physicians better than others.

In addition, Elward said he thinks the study "gives evidence as to the degree to which confusion about the severity of asthma and its control has been confusing for family physicians." According to him, what is needed now is a longitudinal study of asthma care that helps family physicians understand the clinical course of the disease and its treatment over time. That study also needs to take into account factors such as seasonal exacerbations, which is not something that was studied in the Annals article.

Elward also noted that EPR-2 was updated by The Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma in 2007.

EPR-3 is the first comprehensive update of the NAEPP asthma guidelines in more than a decade, said Elward. In addition, the NAEPP is developing an implementation report that will be available to all physicians who treat asthmatic patients. This report will provide information on ways to use the EPR-3 guidelines in clinical practice.

Certain areas of concern are addressed in the new guidelines, including the isolated use of LABAs by certain physicians, according to Elward. The new guidelines also provide information on using LABAs in conjunction with inhaled corticosteroids, and a recommendation to use steroids and LABAs, rather than leukotrienes, as a first-line treatment.