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Am Fam Physician. 2005;72(4):690

In an attempt to improve the care of patients with asthma, the National Asthma Education and Prevention Program developed management guidelines that included severity assessment, monitoring, environmental control, and promotion of patient-physician partnerships. Despite these guidelines, current practices fall short on implementation, and there is still a high prevalence of inadequate asthma control. In multiple studies, only one fourth to one half of children with high-risk asthma used inhaled anti-inflammatory medications on a daily basis. Multiple physician-directed attempts to improve compliance with these guidelines have yielded little or no improvement. Multilevel interventions target patients and physicians in the clinical environment. Most of the published multilevel interventions have studied referral models rather than models based on primary care. Lozano and colleagues evaluated physician education and organizational change and its impact on asthma control in primary care.

The trial was a three-arm cluster randomized controlled study over two years. The interventions studied were: a peer leader education intervention, a planned care intervention incorporating organizational change along with a peer leader, and no intervention except disseminating guidelines and printed patient education material (usual care). The setting for the study was 42 primary care practices. Participants were children three to 17 years of age with mild to moderate persistent asthma. The peer leader education intervention trained one physician for each practice site to provide guidelines and other information to their colleagues. The organizational change intervention consisted of planned asthma care visits with a trained asthma nurse and included a standardized assessment of asthma, support and participation in care planning, and self-management support for families. The main outcomes measured included days with asthma symptoms, asthma-specific health status, and frequency of brief courses of oral steroids.

A total of 638 children participated in the study, and 55 percent reported using controller medications before the study. Before the intervention, the mean annualized asthma symptom days for the group was 107.4 days. Children in the peer education group had fewer symptom days per year, but this statistic was not significantly different than the usual care group. Both interventions had significantly lower rates of steroid use per year compared with the usual care group. The planned care group had significantly fewer asthma symptom days and greater adherence to controller use compared with the usual care group.

The authors conclude that a combination of peer leader education and nurse-mediated organizational changes is an effective model for improving the care for children with asthma in the primary care setting. They add that peer leader education also may serve as a model for improving asthma management, although it is less effective than nurse-mediated organizational change.

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