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Asthma Research

Asthma Guidelines

Dr. Ting

Multicolored simplified asthma guideline reminder(msagr) for better adherence to national/global asthma guidelines

Background: Clinicians in general have not widely and consistently used asthma guidelines in their practices around the world. This study identifies reasons for the poor adherence to asthma guidelines by primary care physicians (PCPs), and simultaneously introduces multicolored simplified asthma guideline reminder (msagr) as a practical tool to enhance adherence to asthma guidelines.

Methods: Sixty-nine PCPs were given a simple, one-page, fill-in-the-blank questionnaire on the classification of asthma severity as defined in National Asthma Education and Prevention Program guidelines, using patients' symptoms, peak expiratory flow rate (PEFR)/forced expiratory volume in 1 second (FEV1) value, PEFR variability, and step therapy based on asthma severity. Also, they were given a questionnaire on barriers to using asthma guidelines and msagr for evaluation. In one targeted community, free copies of msagr were made available to PCPs, and data on emergency room visits and hospitalization of asthmatic patients were analyzed.

Results: Of the PCPs, 16% correctly classified mild, intermittent asthma, 13% mild, persistent asthma, 8% moderate, persistent asthma, and 8% severe, persistent asthma based on the combined patient's symptoms, PEFR or FEV1 value and PEFR variability as defined in National Asthma Education and Prevention Program guidelines. One hundred percent of the PCPs chose inhaled 2-agonists as quick relief medication. Fifty percent of the PCPs chose inhaled steroids, leukotriene antagonists, oral theophylline, and long acting -agonists in various combinations for different severity of asthma. Eighty percent of the physicians failed to select the appropriate dosages of inhaled steroids for different severities of asthma. Ninety-five percent of PCPs reported that msagr made using the guidelines easier for them. In the targeted community, asthma-related emergency room visits decreased 22.5% and hospitalizations by 26.9%. [ Full Article ]
Index
Introduction
Methods
Results
Discussion
Conclusion
Acknowledgments
References
Conclusions: This is the first study that identified the reasons for poor adherence to asthma guidelines by PCPs, and introduced msagr as a practical "low-tech" tool to promote better adherence to asthma guidelines. msagr presents patient-specific recommendations, based on asthma guidelines in a user-friendly format that can save the physician time in real-world primary care settings, where such information is often needed instantly. The overwhelming majority of PCPs strongly agreed that msagr helped them recall the classification of asthma severity in a timely manner, to inquire about various triggers, and to use step therapy accurately and confidently. In one targeted community, msagr helped clinicians in primary care settings to achieve better asthma outcomes and to reduce both emergency room visits and hospitalizations.

Annals of Allergy, Asthma, & Immunology ©2002;88:326-330.
Charts
Study Participants
Classifying Asthma

Downloadable Forms:
(msagr) front and back
Evaluation of msagr

INTRODUCTION

Asthma represents one of the most common chronic diseases throughout the world.1 It is estimated that 4 to 12% of the population suffers from asthma both in developed and developing countries. The National Heart, Lung, and Blood Institute of the National Institutes of Health initially published guidelines for the diagnosis and management of asthma in 1991, and these guidelines were updated in 1997. The National Asthma Education and Prevention Program2 (NAEPP) is an evidence-based document designed to help clinicians make appropriate decision for their patients and to reduce undesirable variation in the care of asthmatic patients. Based on similar principles, the Global Initiative on Asthma1 (GINA) was launched in 1995. However, the clinicians in United States3,4,5,6 and in other countries 7, 8,9,10 have not widely and consistently used these asthma guidelines in their practices. Recent surveys11,12 in our border region revealed that 70 to 98% of the asthmatic children used an albuterol inhaler regularly, and only 20 to 30% of these children have used long-term controller agents intermittently. The apparent dependency on rescue inhalers as a cornerstone of asthma therapy prompted the need to conduct this study.

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METHODS

A simple study was conducted to investigate the etiology of the poor adherence to asthma guidelines in the southwest border region of the United States. The 69 primary care providers in the study (Table 1) were given a simple, one-page, fill-in-the-blank questionnaire on the classification of asthma severity as defined in NAEPP guidelines using patients' symptoms, peak expiratory flow rate (PEFR)/forced expiratory volume in 1 second (FEV1) value, PEFR percentage variability, and step therapy based on asthma severity. A single page questionnaire on the barriers to asthma guidelines was also administered. Then the msagr and how to use it was explained to the primary care physicians (PCPs). In one targeted community of 50,000 with one acute care hospital and nearly 90 physicians, free copies of msagr were made available to PCPs on a voluntary basis. Data on emergency room visits and hospitalizations related to asthmatic patients for the 12 months after the introduction of msagr and the previous 3 years were analyzed.

Table 1

Table 1. Study Participants (click on to enlarge)

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RESULTS
As shown in Fig 1, an overwhelming majority of the PCPs were unable to correctly identify the four classes of asthma: 1) mild, intermittent, 2) mild, persistent, 3) moderate, persistent, and 4) severe, persistent, based on patient's asthma symptoms, FEV1/PEFR value and PEFR variability as defined in NAEPP guidelines. One hundred percent of the PCPs correctly chose inhaled 2-agonists as the quick relief medication for all classes of asthma severity. Fifty percent of the PCPs chose inhaled steroids, leukotriene antagonists, oral theophylline, and long acting -agonists (oral and inhaled) in various combinations for mild, moderate and persistent asthma as long-term controller agents. Eighty percent of the physicians, who prescribed inhaled steroids, failed to select appropriate dosages for different severity of asthma. This failure occurred even though 95% of PCPs knew of the existence of asthma guidelines, and 70% had attended asthma guidelines-related presentation 3 to 6 months before participating in this study.

Figure 1

Figure 1.(click on to enlarge)
Sixteen percent of the primary care clinicians correctly classified mild, intermittent asthma, 13% mild, persistent asthma, 8% moderate, persistent asthma, and 8% severe, persistent asthma based on the combined patient's symptoms, PEFR or FEV1 value, and PEFR variability as defined in NAEPP guidelines

Common reasons cited by PCPs for poor adherence to the asthma guidelines included:

  1. Often do not remember the exact classification of asthma severity by patient's symptoms, FEV1/PEFR value, PEFR variability, and the exact step therapy based on asthma severity in their busy practice (90%).
  2. Often do not remember the various brands of inhaled steroids and their exact dosages for different asthma severity (75%).
  3. Often do not remember to ask about various triggers of asthma (65%).
  4. Often do not have sufficient time or resources to teach patients how to use inhalers and PEFR meters or provide asthma education and an asthma action plan (60%).
  5. On the evaluation of msagr, 95% of the participating physicians strongly agreed that msagr helped them to recall the classification of asthma severity in a timely manner, to inquire about various triggers, and to use step therapy accurately and confidently.

On the evaluation of msagr, 95% of the participating physicians strongly agreed that msagr helped them to recall the classification of asthma severity in a timely manner, to inquire about various triggers, and to use step therapy accurately and confidently.

Asthma outcomes seemed to improve in the target community. From 1997 to 2000, an average of 276 patients with asthma were treated annually in the emergency room. The mean number of hospitalizations for asthma care was 119. In the 12 months (2000 to 2001) after the voluntary introduction of msagr, annual emergency room visits by asthmatic patients fell to 214 (22.46% reduction), and the total number of asthmatic patients hospitalized lessened to 87 (26.89% reduction). This was associated with a remarkable annual 18% increase in the sales of inhaled controller agents (steroids) among PCPs, but no increase was noted among specialists during the same periods.

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DISCUSSION

Both the NAAEP2 and GINA 1 guidelines focusing on evaluating and monitoring asthma severity, identifying triggers, providing optimal pharmacotherapy, and instituting patient education. However, surveys conducted by Thompson 7 in New Zealand; Armstrong et al8 in the United Kingdom; Vernejoux9 in France; the Isis Research Group10 from the Asia-Pacific region and several national studies 3,4,5,6 showed that practicing clinicians in general have not widely and consistently used these guidelines. However, none of the studies provided a solution to address the poor adherence to asthma guidelines. msagr was introduced as a practical tool to promote better adherence to asthma guidelines after identifying the barriers to asthma compliance among PCPs. Clearly, the majority of the clinicians knew of the existence of NAEPP guidelines, but had difficulty recalling the exact classifications of disease severity and selecting optimal therapy of inhaled steroids with various dosages for different severities of asthma. Several reviews have shown that computer-based clinical reminder systems that present patient-specific recommendation in a time-saving format have changed clinician behavior and improved the delivery of acute, chronic, and preventive medical care. 13,14,15 However, to develop and implement a "high-tech" asthma guidelines clinical reminder system is not realistic for most clinicians who take care of asthmatic patients, especially in the border region, inner-city areas, and developing countries. Therefore, out of economic necessity, a simple, practical, single sheet, low cost, low-tech, user-friendly, and visually attractive multicolored simplified asthma guideline reminder (msagr), Fig 2, a and b was designed.

Figure 2. (a) msagr front page. (b) msagr back page.

Page 1Page 2

msagr is self-explanatory. Major features include: box 1, asthma's symptoms, triggers, and evaluation; box 2, classification of asthma severity by symptoms, nocturnal symptoms, PEFR or FEV1, and PEFR variability; and box 3, step therapy based on asthma severity. Color-coded arrows link boxes 2 and 3. Color-coded dialog boxes enhance instant recognition of the appropriate recommended long-term daily medications for mild, moderate, and severe, persistent asthma. Box 4 contains color-coded columns with estimated comparative daily dosages of inhaled steroids for both adults and children older than 5 years of age.

The pressure of the current-day managed care environment places many limits on practicing physicians, including time spent with the patients. msagr presents relevant patient-specific recommendations based on the asthma guidelines in a user-friendly format that can save the physician time in primary care settings, where such information is often needed instantly. Obviously, msagr can neither force clinicians to provide asthma education nor influence patients' compliance. However, msagr contains reminders to clinicians to provide asthma education to patients. Both GINA and NAEPP guidelines consider inhaled anti-inflammatory agents as first-line therapy. With msagr, the doses chosen for asthma care are likely to be more appropriate for the patient's severity. msagr can be used with minimal modification in developed countries where inhaled steroids are widely available. In certain developing countries, financial barriers16 to inhaled steroids use may require alteration of msagr to adjust to each area's unique socioeconomic status, local society's views, values, expectations, and acceptance of different asthma therapies. In one targeted community, voluntary utilization of msagr by PCPs seemed to cause an approximately 25% reduction in asthma-related hospitalizations and emergency room visits. This represented a substantial medical cost saving for this one community.

A web site has been created to facilitate the dissemination of msagr. The overwhelming acceptance (Fig 3) and hundreds of positive comments received from physicians and other health care providers, clearly suggest a need for user-friendly simplified clinical guidelines, not only in asthma but also in other chronic diseases such as hypertension, diabetes mellitus, and depression.

Figure 3

Figure 3. Evaluation of msagr by 500 clinicians across the country.


Q1. Do you agree that the msagr helps you to classify your patient's asthma severity promptly?
Question 1

Q2. Do you agree that the msagr reminds you to inquire of various possible asthma triggers on your asthmatic patients?
Question 2

Q3. Do you agree that the msagr helps you to follow Step Therapy Based on Asthma Severity?
Question 3

Q4. Do you agree that the msagr reminds you to prescribe the recommended dosages of inhaled steroid for different severity of asthma?
Question 4

Q5. Do you agree that the msagr reminds you to educate your patient on inflammatory nature of asthma?
Question 5

Q6. Do you agree that the msagr reminds you to teach your patient on PEFR Meter, inhaler technique, and to provide asthma action plan?

Question 6

Q7. Do you agree that the msagr can enhance your adherence to asthma guidelines in your practice?
Question 7

Q8. Do you agree that the msagr should be disseminated to all clinicians in the trenches?
Question 8

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CONCLUSION

This is the first study that identified barriers for the poor adherence to asthma guidelines by PCPs, and simultaneously introduced a practical tool (msagr) to enhance adherence to asthma guidelines in primary care settings. Voluntary acceptance and utilization of msagr by clinicians resulted in fewer emergency room visits and hospitalizations for their asthmatic patients. This provided documentation that a low-cost, practical clinical tool can help PCPs achieve better asthma outcomes in real-world primary care settings. msagr represents a local effort, which, by example, may influence methods to increase the implementation of asthma guidelines and perhaps other clinical guidelines, nationally and internationally.

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ACKNOWLEDGMENTS

This article is dedicated to primary care clinicians who inspired me to design a practical tool to promote better adherence to asthma guidelines in real-world busy practice. I thank Luis Garcia, RPH and Evelyn Chapman, RN for their enthusiastic support of the msagr project and Dr. Marie A. Leiner, research instructor for her valuable assistance in compiling data. Jane Ackart Caprio, Hospital Information System ENMMC for asthma ER/Hospitalizations statistics. NDC/IMF for asthma medications data.

Texas Tech University, Department of Pediatrics, El Paso, TX, and Allergy and Asthma Center of the Southwest, Las Cruces, New Mexico.

Received for publication July 11, 2001.

Accepted for publication in revised form October 31, 2001.

Requests for reprints should be addressed to:

Stanislaus Ting, MD; Texas Tech University; 4801 Alberta Avenue; El Paso, TX 79905; Stan.Ting@ttuhsc.edu;

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REFERENCES

1. National Heart, Lung, and Blood Institute. Global strategy for asthma management and prevention. Global initiative for asthma. 1995. Bethesda, MD: National Institutes of Health. Publication no 95-3659.

2. National Asthma Education and Prevention Program. Expert panel report 2: April 1997. Bethesda, MD: National Institutes of Health. Publication no 97-4051.

3. Doerschug KC, Peterson MW, Dayton CS, Kline JN. Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med 1999;159:1735-1741. Medline

4. Legorreta AP, Christian-Herman J, O'Connor RD, et al. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med 1998;158:457-464. Medline

5. Vollmer WM, O'Hollaren M, Ettinger KM, et al. Specialty differences in the management of asthma. A cross-sectional assessment of allergists' patients and generalists' patients in a large HMO. Arch Intern Med 1997;157:1201-1208. Medline

6. Carl JM, Oppenheimer JJ, Bielory L. Comparison of emergency room asthma care to national guidelines. Ann Allergy Asthma Immunol 1999;83:208-211. Medline

7. Thompson R, Dixon F, Watt J, et al. Prescribing for childhood asthma in the Wellington area: comparison with international guidelines. N Z Med J 1993;106:81-83. Medline

8. Armstrong D, Fry J, Armstrong P. General practitioners' views of clinical guidelines for the management of asthma. Int J Qual Health Care 1994;6:199-202. Medline

9. Vernejoux JM, Tunon JM, Guizard AV, and et al. Moderate asthma in adults. Rev Mal Respir 1996;13:499-505. Medline

10. Isis Research Group. Asthma Insights and Reality in Asia Pacific (AIRIAP), A preliminary report 2001.

11. Ting S, Leiner MA, et al. Asthma prevalence and current state of asthma among school children in border city. Ann Allergy Asthma Immunol 2000;84:164.

12. Ting S, Leiner MA, et al. Current state of asthma along the border-region. Manuscript in preparation.

13. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 1998;280:1339-1346. Medline

14. Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research. Ann Intern Med 1994;120:135-142. Medline

15. McDonald CJ, Hui SL, Smith DM, et al. Reminders to physicians from an introspective computer medical record. A two-year randomized trial. Ann Intern Med 1984;100:130-138. Medline

16. Watson JP, Lewis RA. Is asthma treatment affordable in developing countries? Thorax 1997;52:605-607. Medline

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