Background: Asthma is a common chronic illness in children. Despite recent improvements in asthma therapy, there is still significant morbidity. National guidelines on the management of asthma have been published, and research has found that following these guidelines improves asthma outcomes. However, multiple studies have shown that physicians generally do not follow these guidelines. Persons least likely to receive appropriate preventive asthma treatment are children from poor or minority backgrounds.
One opportunity to use asthma guidelines is during the office visit, but studies have shown that physicians often do not document disease severity, underestimate symptom severity, and fail to consistently provide written action plans and asthma education. Halterman and associates evaluated the use of a physician prompter (a one-page questionnaire) for asthma severity and guideline recommendations during visits with inner-city children with persistent asthma.
The Study: This study was conducted in two inner-city pediatric practices that serve mainly low-income and minority patients. Children were eligible if they were two to 12 years of age, had mild or more severe persistent asthma, and had at least two asthma exacerbations in the two years preceding the study. Children who had medical illnesses that could complicate asthma control were excluded.
Each of the 246 children enrolled in the study had a baseline assessment that included household demographics, asthma symptom severity, medication use, and environmental tobacco smoke exposure. After the initial assessment, the children were randomized into two groups: 122 were assigned to the physician-prompted group, and 124 were assigned to the usual care group. The prompted group received an asthma report and action recommendation form (see accompanying figure). The prompt included information about current asthma symptoms, classification of asthma severity, and recommendations for treatment based on national guidelines. Also, information about the child's history of exposure to tobacco smoke and a prompt for discussing the reduction of this exposure were included. The questionnaire was given to the parent with instructions to return it to the physician. Outcome measures included any asthma preventive action provided during the office visit, which was assessed via telephone interview with the child's parent.
Results: The physician-prompted group was more likely to receive preventive measures compared with the usual care group (87 versus 69 percent). In particular, children in the physician-prompted group were more likely to have discussions about their asthma, receive an action plan for treatment, and be recommended for follow-up care compared with the usual care group. The odds ratio (OR) for any preventive measure in the physician-prompted group was significantly higher than in the usual care group (OR = 3.1; 95% confidence interval, 1.4 to 6.6). Interventions in the physician-prompted group that had an OR higher than 2.0 included providing an asthma action plan and counseling to reduce tobacco smoke exposure.
Conclusion: The authors conclude that use of a physician prompt that includes severity of the disease and care guidelines at an office visit can improve the delivery of preventive asthma care. They add that because urban children have the highest risk of asthma morbidity, this intervention has the potential to reduce morbidity in this population.