- Email: [email protected]
Asthma Care Practices, Perceptions, and Beliefs of Chicago-Area Asthma Specialists
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rates of hospitalization of children really mean? N Engl J Med 1989; 320:1200 –1211 Lenfant C, Hurd SS. Special report: National Asthma Education Program. Chest 1990; 98:226 –227 National Asthma Education, and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 1991. NIH publication 91–3642 Burt CW, Knapp DE. Ambulatory care visits for asthma: United States, 1993–1994; Hyattsville, MD: National Center for Health Statistics; 1996. Advance data from vital and health statistics No. 277 Crain EF, Weiss KB, Fagan MJ. Pediatric asthma care in US emergency departments. Arch Pediatr Adolesc Med 1995; 149:893–901 Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management. Arch Intern Med 1997; 157: 1193–1200 Gourgoulianis KI, Hamos B, Christou K, et al. Prescription of medications by primary care physicians in the light of asthma guidelines. Respiration 1998; 65:18 –20 Wolle JM, Cwi J. Physicians’ prevention-related practice behaviors in treating adult patients with asthma: results of a national survey. J Asthma 1995; 32:131–140 National Committee for Quality Assurance. Minnesota QARI demonstration project: a focused review of asthma care, a practice setting survey. Internal report. Washington, DC: National Committee for Quality Assurance; 1995 Steinwachs DM, Wu A, Skinner EA, et al. Asthma Patient Outcomes Study: baseline survey summary report. Bloomington, MN: The Health Outcomes Institute, 1995 National Asthma Education, and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH publication 97– 4051 AMA Physician Masterfile. Chicago, IL: American Medical Association, Department of Data Survey, and Planning, Division of Survey, and Data Resources; 1996 Eggleston PA, Malveaux FJ, Butz AM, et al. Medications used by children with asthma living in the inner city. Pediatrics 1998; 101:349 –354 Stempel DA, Durcannin-Robbins JF, Hedblom EC, et al. Drug utilization evaluation identifies costs associated with high use of beta-adrenergic agonists. Ann Allergy Asthma Immunol 1996; 76:153–158 American Academy of Allergy, Asthma, and Immunology. Pediatric asthma: promoting best practice; guide to managing asthma in children. J Allergy Clin Immunol Monograph, Milwaukee, WI (in press) Warner JO, Naspitz CK, Cropp GJA, eds. Third International Pediatric Consensus: Statement on the Management of Childhood Asthma. Pediatr Pulmonol 1998; 25:1–17 Lieu TA, Quesenberry CP, Capra AM, et al. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics 1997; 100:334 –341 Inouye J, Kristopatis R, Stone E, et al. Physicians’ changing attitudes toward guidelines. J Gen Intern Med 1998; 13:324 – 326 Picken HA, Greenfield S, Teres D, et al. Effect of local standards on the implementation of national guidelines for asthma: primary care agreement with national asthma guidelines. J Gen Intern Med 1998; 13:659 – 663
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Asthma Care Practices, Perceptions, and Beliefs of Chicago-Area Asthma Specialists* James N. Moy, MD; Evalyn N. Grant, MD; Karen Turner-Roan, MPH; Tao Li, PhD; and Kevin B. Weiss, MD; for the Chicago Asthma Surveillance Initiative Project Team†
Introduction: Few studies have closely explored how well physicians who consider themselves specialists in asthma adhere to national guideline recommendations for the diagnosis and treatment of asthma. The purpose of this study is to characterize current knowledge, attitudes, beliefs, and self-reported treatment practices of the asthma specialists working in one large metropolitan area. Methods: In 1997, a cross-sectional survey was mailed to asthma specialists (allergists or pulmonologists) engaged in direct patient care with a practice location in the Chicago area (Cook County or one of the five surrounding counties). An approximately 50% random sample of asthma specialists was surveyed. The survey included items on (1) asthma diagnosis; (2) clinical monitoring of asthma patients; (3) pharmacologic and nonpharmacologic asthma treatment; (4) opinions and beliefs about asthma treatment options and reasons for referrals; (5) involvement in continuing medical education; (6) experiences with managed care; (7) use of asthma practice guidelines; (8) demographic information about the respondents; and (9) characteristics of the practice settings. Results: A total of 113 eligible surveys were returned (response rate, 72.0%). Ninety-nine percent of the respondents indicated they would prescribe inhaled corticosteroids for patients > 5 years old with moderate persistent asthma, and 85.5% would prescribe them for patients < 5 years old. The respondents reported that 71.2% of their patients with moderate or severe persistent asthma were routinely given written treatment plans. The use of these plans was reported more frequently by allergists than pulmonologists (77.6% vs 58.9%, p 5 0.01). Nearly half of the respondents were involved in the development of hospital-based asthma programs; fewer (14.9%) *From the Department of Pediatrics, Cook County Children’s Hospital (Dr. Moy), the Department of Immunology/Microbiology (Dr. Grant), and the Center for Health Services Research, Rush Primary Care Institute (Ms. Turner-Roan, Drs. Li, and Weiss), Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL. †See Appendix for other members of the CASI Project Team. CASI is funded by a grant from the Otho S.A. Sprague Memorial Institute. Correspondence to: Kevin B. Weiss, MD, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke’s Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612 Asthma in Chicago
were involved in developing asthma programs for managed care organizations. A majority (63.4%) of the physicians had given a formal professional education presentation on asthma in the past year. A majority of the respondents who care for patients under managed care contracts reported that these patients have encountered barriers to access in seeking specialty care. Conclusion: The results suggest that asthma specialists in the Chicago area are providing asthma care that is, in many ways, consistent with national guidelines. However, there are also important differences in care that are not consistent with the guideline recommendations. Perhaps even more notable are differences in reported asthma care between the two subspecialty groups of allergists and pulmonologists. The effect of these differences on the management of persons with asthma is not known. It is hoped that information from this community-based survey will serve to catalyze discussions among Chicago-area asthma specialists as to how they might envision improving care for persons with asthma in their community. (CHEST 1999; 116:154S–162S) Abbreviations: AMA 5 American Medical Association; CASI 5 Chicago Asthma Surveillance Initiative; NAEPP 5 National Asthma Education and Prevention Program is often assumed that much of the leadership for defining I toptimal medical care in the primary care setting emerges
from the knowledge, attitudes, beliefs, and actual practice patterns of medical care subspecialists. Subspecialty wisdom is conveyed to the primary care physicians through a variety of mechanisms, such as consultation, formal educational sessions, and scholarly publications. More recently, there has been extensive subspecialty involvement in the development and dissemination of clinical practice guidelines. And yet, there is limited published information on the normative practice patterns of subspecialists, even for many common chronic conditions. Asthma is one of the common chronic conditions for which there has been substantive subspecialty input into nationally accepted clinical practice guidelines. Asthma subspecialists were instrumental in both the design and dissemination of the expert panel report, “Guidelines for the Diagnosis and Management of Asthma,” of the National Asthma Education and Prevention Program (NAEPP), first published in 19911 and subsequently revised in 1997.2 However, to date, few studies have closely explored how well physicians who consider themselves specialists in asthma care adhere to these guidelines.3–7 None of these studies examine the similarities or differences in reported care between the two different subspecialties of allergy and pulmonology. Yet collectively, these two groups constitute nearly all physicians who are commonly considered to be asthma specialists. Chicago has one of the highest asthma mortality rates in the nation.8 It has been suggested that quality of and access to health care are key factors relating to this disproportionate mortality. Therefore, within the Chicago
community, there is a large concern over the quality of care provided by its physicians. The purpose of this study was to characterize the current knowledge, attitudes, beliefs, and self-reported practices of asthma specialists— both allergists and pulmonologists—working in the Chicago metropolitan area. A secondary purpose was to examine differences between allergists and pulmonologists for several key aspects of asthma care.
Materials and Methods A cross-sectional written survey was used to assess asthma care among Chicago-area asthma specialists during 1997. Study Population Chicago-area asthma specialists were identified from the American Medical Association (AMA) 1995 Masterfile,9 which contains names and professional information on all practicing physicians in the United States. Physicians meeting the following criteria were identified: (1) engaged in direct patient care; (2) practice location in Cook, Lake, Du Page, McHenry, Kane, or Will counties, IL; and (3) primary or secondary specialty of allergy, allergy and immunology, allergy and immunology/diagnostic laboratory immunology, pulmonary diseases, critical care medicine, or pediatric pulmonology. Survey Instrument A self-administered survey instrument was constructed on the basis of existing surveys developed by the National Heart, Lung, and Blood Institute,4 the Quality Assurance Reform Initiative project of the National Committee on Quality Assurance,10 and the Managed Health Care Association.11 An advisory panel of local allergists and pulmonologists reviewed the survey items and content areas. The survey was revised on the basis of panel recommendations to include additional questions reflecting new content areas. The final survey instrument consisted of 174 items covering the following content areas of asthma care: (1) diagnosis; (2) clinical monitoring; (3) pharmacologic and nonpharmacologic treatment; (4) opinions and beliefs about treatment options and reasons for referrals; (5) involvement in continuing medical education; (6) experiences with managed care; (7) use of asthma practice guidelines; (8) respondent demographics; and (9) characteristics of practice settings. Sampling Methods From the AMA Masterfile, 364 specialty physicians were identified. The 364 listings were subsequently sorted into one of three groups: group 1 consisted of 244 physicians with a primary specialty of allergy, pulmonology, pediatric pulmonology, or critical care medicine; group 2 consisted of 109 physicians with a secondary specialty of allergy, pulmonology, pediatric pulmonology, or critical care medicine; and group 3 consisted of 11 physicians with a combination of either allergy, pulmonology, pediatric pulmonology, and critical care medicine as their primary and secondary specialty. The survey sample included all 11 physicians in group 3 and 50% of the physicians in groups 1 and 2. Physicians were considered ineligible if they had retired, were deceased, or had moved their practice outside of the six-county study area. Survey Administration The survey was mailed to the sample population along with a cover letter and a postage-paid return envelope. The physicians CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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were asked to return their surveys by mail or fax. To maximize the response rate, the first mailing was supplemented by additional mailings and telephone calls to nonrespondents. Data Analysis Completed surveys were excluded from this analysis if the respondent reported that asthma patients constitute , 1% of their practice. For the survey items that inquired about care for children , 5 years old, responses from physicians who did not provide care for patients in that age group were also excluded from the analysis. For the comparisons between pulmonologists and allergists, the respondents were classified by specialty on the basis of their response to the question, “How would you best describe your current medical specialty?” Respondents were also asked whether they were Board certified or eligible in each specialty. Those that reported Board certification or eligibility in pulmonary medicine or pediatric pulmonary medicine were classified as pulmonologists. Those that reported Board certification or eligibility in allergy and clinical immunology were classified as allergists. Data analysis was conducted using SAS computer software (SAS Version 6.12; SAS Institute; Cary, NC). When appropriate, tests of significance were performed using x2 or nonparametric analysis of variance. Means are reported with SE. For the purposes of this discussion, the term “very few” is used to describe responses reported by , 20% of the respondents, “minority” refers to 20 to 49%, “majority” refers to 50 to 79%, and “nearly all” refers to 80 to 100%. This project was approved by the Institutional Review Board of Rush-Presbyterian-St. Luke’s Medical Center.
Results Thirty of the 187 physicians in the original sample were ineligible. Of the remaining 157, 113 surveys were returned, for a response rate of 72.0%. Ten surveys were subsequently excluded because the respondents did not identify themselves as either pulmonologists or allergists, leaving 103 available for analysis.
General Characteristics of Physicians and Practices Table 1 displays some of the demographic characteristics of the respondents in comparison to the other
Chicago-area pulmonologists and allergists in the 1995 AMA Masterfile. The sample respondents were similar to the other Chicago-area asthma specialists by specialty distribution, age, sex, years since graduation, United States graduation, and type of practice setting. Two surveys were excluded from additional analysis because the respondents reported that , 1% of their patients had asthma. Of the remaining 101 respondents, 38 (37.6%) identified themselves as pulmonologists and 59 (58.4%) identified themselves as allergists. Four respondents (4.0%) identified themselves as specialists in both pulmonology and allergy. These four were included in the overall analyses, but were excluded from analyses comparing responses of pulmonologists with those of allergists. The respondents estimated that patients with asthma represented an average of 46.5 6 2.4% of their practice, with allergists reporting slightly higher percentages than pulmonologists (49.0 6 0.03% vs 40.0 6 0.04%, respectively; p 5 0.08).
Approach to Evaluation and Monitoring of Asthma Patients The survey examined the respondents’ opinions regarding what percent of patients with newly diagnosed moderate persistent asthma should receive certain diagnostic tests. As seen in Table 2, spirometry was recommended for nearly all patients. The respondents reported that the majority of asthma patients should receive a trial of daily peak flow monitoring, a chest radiograph, and testing for IgE-mediated allergies and that very few patients should require a sputum examination and staining for eosinophilia. The pulmonologists and allergists generally agreed on most items, with two notable exceptions. The first was that pulmonologists indicated that a higher percentage of patients should receive chest radiographs (87.9 6 4.6%) as compared with the allergists’ response (47.5 6 5.2% of
Table 1—Characteristics of CASI Asthma Specialist Survey Respondents Compared With the Chicago-Area Specialists in the 1995 AMA Masterfile* Characteristics Subspecialty‡ Pulmonary medicine, % Allergy and immunology, % Pediatric pulmonary medicine, % Age, yr (mean 6 SEM) Female gender, % Years since medical school graduation, mean (SE) United States graduate, % Type of practice Office-based, % Hospital-based, % Percentage of asthma patients in practice, mean (SE)
Respondents, n 5 103
AMA Masterfile†, n 5 261
p Value
35.9 61.2 2.9 51.9 (1.0) 28.2 26.4 (10.3) 66.0
36.5 51.0 3.5 52.1 (0.8) 23.8 26.3 (12.4) 62.5
0.21
0.88 0.38 0.97 0.50
81.6 5.8 46.5 (2.4)
73.6 8.4 —
0.11 0.40 —
*Based on data reported in the 1995 AMA Masterfile.9 Does not include information on the 10 respondents who were deemed ineligible. †Excluding respondent data. ‡Primary or secondary medical specialty. §Based on survey responses. 156S
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Table 2—Approach to Evaluation and Monitoring of Asthma as Reported by Chicago-Area Specialists* Approaches
All Respondents, n 5 101†
Pulmonologists, n 5 38‡
Allergists, n 5 59‡
p Value
Patients with newly diagnosed moderate persistent asthma who should receive the following diagnostic techniques as part of their evaluation, mean (SE) Spirometry, % 87.9 (2.4) 93.6 (2.5) 84.7 (3.6) 0.07 Chest radiograph, % 61.5 (4.0) 87.9 (4.0) 47.5 (5.2) , 0.01 Skin testing or RAST, % 61.1 (4.0) 20.2 (3.5) 89.3 (2.8) , 0.01 Sinus radiographs or CT, % 30.2 (2.5) 25.9 (3.9) 33.9 (3.3) 0.12 Trial of daily peak flow monitoring, % 69.5 (3.8) 60.2 (6.3) 74.8 (4.8) 0.06 Sputum examinations and stain for eosinophilia, % 12.3 (2.6) 13.1 (4.4) 12.6 (3.5) 0.93 Physicians who order the following diagnostic tests as part of their routine evaluation of patients with moderate or severe asthma Sinus radiographs, % 4.0 5.3 3.5 0.68 CT of the sinuses, % 11.9 5.3 16.9 0.09 MRI of the sinuses, % 0.0 0.0 0.0 — Nasal speculum examination, % 60.2 36.8 78.6 , 0.01 Rhinolaryngoscopy, % 3.0 0.0 5.2 0.25 UGI for GERD, % 4.0 7.9 1.7 0.14 Esophageal pH testing for GERD, % 1.0 0.0 1.7 0.42 Use of peak flow or spirometry Physicians who find home peak flow monitoring to be often useful for 60.0 50.0 65.5 0.13 management of moderate to severe persistent asthma, % Patients $ 5 years with moderate or severe persistent asthma that are 69.3 (3.6) 52.6 (5.8) 79.5 (4.2) , 0.01 prescribed home peak flow monitoring, mean % (SE) Physicians who “often” performed PEFR or PFT for acutely symptomatic 75.0 57.9 84.5 , 0.01 patients, % Physicians who “often” performed PEFR or PFT for asymptomatic 51.0 34.2 60.3 0.01 patients, % *Individual item response rates were . 90% of the sample unless otherwise indicated. RAST 5 radioallergosorbent testing; UGI 5 upper GI series; GERD 5 gastroesophageal reflux disease; PEFR 5 peak expiratory flow rate; PFT 5 pulmonary function tests. †Of the 103 surveys returned, two physicians did not see sufficient numbers of asthma patients to include in the analysis. ‡Four respondents reported themselves as both pulmonologists and allergists and were excluded from the comparisons by specialty type.
patients; p , 0.01). The other notable difference was that the allergists indicated four times as many patients (89.3 6 2.8%) should receive specific IgE allergy testing (radioallergosorbent testing or skin testing) compared with the pulmonologists’ response (20.2 6 3.5% of patients). Table 2 also displays the responses to questions asked about other diagnostic tests for patients with moderate or severe persistent asthma. The specialists reported that, with the exception of the nasal speculum examination, few tests other than those noted above were routinely obtained. When asked about radiographic evaluation of the sinuses, 11.9% of the physicians reported that they routinely ordered CT scans and 4.0% routinely ordered sinus radiographs (p 5 0.04). None of the respondents ordered an MRI of the sinuses as part of their routine examination of persons with moderate or severe asthma. For patients with moderate persistent asthma under good control, 73.3% of the respondents reported scheduling routine visits more frequently than every 6 months; 13.9% indicated they scheduled routine visits less frequently than every 6 months. Very few (7.9%) of the physicians reported that they followed up with office visits only when the patient is symptomatic.
Use of Objective Airway Function Testing The survey also queried the specialists’ opinions on the usefulness of peak flow measurements. As seen in
Table 2, the majority of the respondents indicated that home peak flow monitoring is often useful for patients with moderate-to-severe persistent asthma. On average, the respondents also indicated that the majority of their patients with moderate-to-severe asthma are instructed to monitor peak flow readings at home. In comparing the two types of asthma specialists, the allergists’ patients were more likely to have been prescribed home peak flow monitoring than the pulmonologists’ patients (79.5 6 4.2% vs 52.6 6 5.8%; p , 0.01). The allergists and pulmonologists also differed in their use of objective testing of airway function during an office visit. Overall, 75.0% of the respondents reported performing peak flow measurements or pulmonary function testing “often” for acutely symptomatic patients; by specialty, 84.5% of allergists vs 57.9% of pulmonologists performed these tests “often” (p , 0.01). As for asymptomatic patients, 51.0% of the respondents reported performing these tests “often” during an office visit, and, similar to the acute patient scenario, reported use was higher for allergists than pulmonologists (60.3% vs 34.2%; p 5 0.01). Nearly all (85.3%) the respondents reported that they had a spirometer in their offices, whereas very few (14.9%) reported referring their patients for pulmonary function testing at another hospital, clinic, or asthma specialist. CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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Medications Several of the survey items asked about the types of medications prescribed for patients with mild intermittent, moderate persistent, and severe persistent asthma. Medications Prescribed for Mild Intermittent Asthma: For patients , 5 years old with mild intermittent asthma, nearly all (94.7%) the specialists reported that they were likely to prescribe inhaled b-agonists, and the majority (61.4%) were likely to prescribe cromolyn or nedocromil. Prescription of oral b-agonists (45.6%) and inhaled corticosteroids (30.9%) were reported less frequently. Very few specialists (12.5%) were likely to prescribe theophylline. For patients $ 5 years with mild intermittent asthma, the responses were similar to the younger patients. There were no significant differences in treatment by specialist type for patients with mild intermittent asthma. Medications for Moderate Persistent Asthma: Table 3 characterizes the use of pharmacologic agents in the treatment of persons with moderate persistent asthma. The survey data show that 100% of the respondents were likely to prescribe inhaled b-agonists for patients with
moderate or severe persistent asthma. The respondents were more likely to prescribe oral b-agonists for patients , 5 years of age (36.4%) than for patients $ 5 years (21.5%; p 5 0.05). Ninety-nine percent of the respondents indicated they would prescribe inhaled corticosteroids for patients $ 5 years of age with moderate persistent asthma and 85.5% would prescribe them for patients , 5 years. Forty-five percent of the respondents reported that they were likely to prescribe theophylline for patients $ 5 years of age, whereas 33.3% were likely to prescribe it for patients , 5 years of age. The pulmonologists and allergists generally shared similar opinions on medication management for patients with moderate persistent asthma, with one exception. Nearly twice as many allergists would prescribe the nonsteroidal anti-inflammatory medications, cromolyn or nedocromil, for patients $ 5 years (60.3% of the allergists vs 38.2% of the pulmonologists; p 5 0.04). For children , 5 years of age, 83.9% of the respondents were likely to prescribe cromolyn or nedocromil. Medications Prescribed for Severe Persistent Asthma: For children , 5 years of age with severe persistent
Table 3—Pharmacotherapeutic Practices for Persons With Moderate Asthma as Reported by Chicago-Area Asthma Specialists* Practices
All Respondents, Pulmonologists, Allergists, n 5 101† n 5 38‡ n 5 59‡
p Value
Physicians likely to prescribe the following medications for patients $ 5 yr of age with moderate persistent symptoms Theophylline, % 45.3 37.1 48.2 0.30 Oral b-agonists, % 21.5 19.4 24.1 0.61 Inhaled b-agonists, % 100.0 100.0 100.0 — Systemic steroids, % 37.4 37.1 37.7 0.96 Inhaled steroid, % 99.0 100.0 98.3 0.43 Cromolyn/nedocromil, % 53.1 38.2 60.3 0.04 Physicians likely to prescribe the following medications for patients , 5 yr of age with moderate persistent asthma (n 5 57)§ Theophylline, % 33.3 Oral b-agonists, % 36.4 Inhaled b-agonists, % 100.0 Systemic steroids, % 37.7 Inhaled steroids, % 85.5 Cromolyn/nedocromil, % 83.9 Physicians’ response to the question: “For a patient ($ 5 yr of age) with daily symptoms that respond to tid short-acting inhaled b-agonists as his or her only medication, who is waking up more than twice a month with asthma symptoms, what would you do next?” No change, % 0.0 0.0 0.0 Increase b-agonists, % 1.0 2.6 0.0 0.21 Add theophylline, % 3.0 2.6 3.4 0.83 Add inhaled corticosteroids, % 72.3 71.1 74.6 0.70 Add oral steroids, % 1.0 2.6 0.0 0.21 Add cromolyn/nedocromil, % 9.9 5.3 10.2 0.39 Add inhaled corticosteroids or cromolyn/nedocromil, % 82.2 76.3 84.8 0.30 Add long-acting b-agonists, % 9.9 13.2 8.5 0.50 Other, % 3.0 2.6 3.4 0.83 *Individual item response rates are . 90% of the sample unless otherwise noted. Responses are a percentage of the physicians using each medicine. †Of the 103 surveys returned, two physicians did not see sufficient numbers of asthma patients to include in the analysis. ‡Four respondents reported themselves as both pulmonologists and allergists and were excluded from the comparisons by specialty type. §Physicians who did not provide care for patients , 5 yr of age were excluded from this analysis. Comparisons between allergists and pulmonologists not done for this item because of the low number of pulmonologists providing care for this young age group (n 5 3).
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asthma, the respondents were most likely to prescribe inhaled b-agonists (100.0%), followed by inhaled corticosteroids (98.2%), systemic corticosteroids (89.1%), and cromolyn or nedocromil (69.1%). A minority of the respondents were likely to prescribe theophylline (55.4%) and oral b-agonists (43.4%). For patients $ 5 years of age with severe persistent asthma, the responses were similar to those for the younger patients, with the exceptions that only 48.9% of the physicians reported that they were likely to prescribe cromolyn or nedocromil, but 76.3% were likely to prescribe theophylline. When comparing allergists and pulmonologists, there was only one marginal difference in medication choice for patients with severe persistent asthma. For patients , 5 years with severe persistent asthma, 57.1% of the allergists indicated they would prescribe theophylline, whereas none of the pulmonologists chose theophylline for this age group (p 5 0.05). When asked the question, “For a patient ($ 5 years) with daily symptoms that respond to three times per day short-acting inhaled b-agonists as his or her only medication who is waking up more than twice a month with asthma symptoms, what would you do next?” 82.2% of the respondents indicated they would add inhaled anti-inflammatory medications (72.3% specified inhaled corticosteroids and 9.9% specified cromolyn or nedocromil). Nearly 10% of the respondents reported that they would add a long-acting b-agonist instead of anti-inflammatory medications. There were no significant differences in responses between the allergists and pulmonologists with regard to this question.
Perceptions of the Safety of Inhaled Corticosteroids When asked about the safety of long-term use of inhaled corticosteroids at standard doses, the majority (57.0%) of the respondents answered “very safe.” A minority (41.0%) answered “safe,” and 2.0% were “uncertain.” For patients , 5 years, a minority of the respondents perceived their use as “very safe” (31.8%) or “safe” (44.7%). Approximately 21% of the respondents were unsure of the safety, and 2.4% answered “unsafe.”
Nonpharmacologic Management of Asthma Sixty-six percent of the physicians (98.3% of the allergists and 15.8% of the pulmonologists; p , 0.001) reported using immunotherapy for patients with moderate asthma. On average, these physicians used immunotherapy on 38.0 6 3.2% of their patients with moderate asthma. For all respondents, the most commonly reported environmental control measures recommended for patients with stable moderate or severe asthma were avoidance of household tobacco smoke (97.0%) and removal of pets from the bedroom (87.0%). Recommended use of mattress and pillow covers was reported by 68.3% of the respondents. Only a minority routinely recommended high-efficiency particulate air filters (35.6%) or dehumidification. Routine cleaning of ductwork and avoidance of exercise and physical activity were recommended rarely.
Approach to Asthma Education Regarding asthma patient education, only 11.0% of the respondents reported that they referred their patients to a formal asthma education program. Instead, 87.1% reported that they conducted informal educational programs in their offices. One fourth of the physicians reported that their practices had a dedicated asthma case manager for patients with difficult-to-control asthma. Of the case managers, 66.7% were reported to be registered nurses. Nineteen percent of the physicians reported that their practice had a dedicated nonphysician health educator who delivered formal asthma education. Of the health educators, 65.0% were reported to be registered nurses.
Opinions About Referrals to Asthma Specialists The specialists were asked the question, “which of the following should prompt a primary care physician to refer patients to an asthma specialist?” Nearly all reported that the following should prompt a consultation: a life threatening episode (100.0%), severe persistent asthma (99.0%), continued symptoms on multiple medications (99.0%), hospitalization for asthma (92.1%), and diagnosis in children # 3 years (84.6%). Most of the specialists (59.4%) reported that an emergency department visit was an indication for consultation, and 29.7% viewed a diagnosis of mild persistent asthma as a reason for consultation.
Other Aspects of Asthma Management When asked about asthma practice guidelines, very few of the physicians responded that they did not follow any type of asthma practice guidelines (Table 4). Of the various types of asthma guidelines available, 89.0% of the respondents indicated that they followed the NAEPP guidelines. On average, the respondents reported that 71.2 6 3.6% of their patients with moderate or severe persistent asthma were routinely given written treatment plans. Overall, more allergists than pulmonologists reported use of written treatment plans (77.6 6 4.4% vs 58.9 6 6.5%; p 5 0.01). All of the physicians indicated that patients had 24-h telephone access to their practice. The specialists were asked what they would do if a patient called for an acute but nonlife-threatening asthma exacerbation. Sixty-eight percent of the asthma specialists reported that they would provide a same-day appointment at the office, and very few reported they would instruct the patient to go to the emergency department (14.0%).
Managed Care Issues Ninety-two percent of the respondents reported that managed care patients were a part of their practices. As seen in Figure 1, a majority of the respondents indicated that their patients with managed care coverage have encountered barriers to access in seeking specialty care. More than half of the physicians reported being contacted by either a managed care organization or pharmaceutical CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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Table 4 —Asthma Quality of Care Practice Issues as Reported by Chicago-Area Asthma Specialists* Practice Issues Physicians using the following asthma care practice guidelines NAEPP, % Global Initiative for Asthma, % International Consensus Report, % Other, % Do not use guidelines, % Physicians involved in the development of asthma programs In hospitals, % In managed care organizations, % Other, % Physicians who have given a formal talk or presentation on asthma in the past year, %
All Respondents, n 5 101†
Pulmonologists, n 5 38‡
Allergists, n 5 59‡
p Value
89.0 29.0 25.0 7.0 8.0
89.9 15.8 13.2 7.9 10.5
89.7 36.2 31.0 6.9 6.9
0.98 0.03 0.05 0.85 0.53
46.5 14.9 5.9 63.4
44.7 18.4 0.0 63.2
44.1 13.6 10.2 61.0
0.95 0.52 0.04 0.83
*Individual item response rates were . 90% of the sample unless otherwise noted. NAEPP 5 National Asthma Education and Prevention Program. †Of the 103 surveys returned, two physicians did not see sufficient numbers of asthma patients to include in the analysis. ‡Four respondents reported themselves as both pulmonologists and allergists, and were excluded from the comparisons by specialty type.
benefits manager about their prescribing practices for asthma patients. Figure 1 also shows that significantly more allergists than pulmonologists answered yes to both of these questions.
Asthma Specialists as Educators and Opinion Leaders The respondents were questioned about their involvement in asthma management programs, such as critical pathways, practice guidelines and parameters, or diseasemanagement programs. Nearly half of the respondents were involved in the development of hospital-based programs; few (14.9%) were involved in developing asthma programs for managed care organizations (Table 4). A majority of the physicians had given a formal presentation on asthma in the past year.
Discussion The results of this survey suggest that asthma specialists in the Chicago area report that they are providing asthma
Figure 1. Frequency of specialty physician reports of selected asthma-related issues in managed care. 160S
care that is in many ways consistent with the NAEPP guidelines, particularly in areas such as the following: frequent use of spirometry for the initial diagnosis and monitoring of persons with moderate persistent asthma, prescribing of anti-inflammatory medications for persons with moderate persistent asthma, and providing patients with written action plans. However, the survey data also demonstrate important differences in specialists’ care vs the NAEPP guideline recommendations. For example, although the survey data indicate overall frequent use of peak flow or spirometry for monitoring patients, there was a clear tendency for the specialists to use these tools much more commonly for acutely symptomatic patients than for asymptomatic patients. The specialists also reported moderate use of inhaled steroids for patients with mild intermittent asthma. These routine asthma care practice patterns, although inconsistent with guideline recommendations, do not, in and of themselves, suggest poor clinical care. Rather, they present issues for further discussion on what might be considered normative specialty care. The inconsistencies in asthma care between the specialist groups also have the potential to deliver confusing messages to primary-care physicians and their patients. Some of these differences, such as higher use of immunotherapy by allergists, are not surprising. However, differences in the use of diagnostic imaging (eg, chest and sinus radiographs) and testing for allergen sensitivity (either by skin prick or radioallergosorbent test) are of greater concern. Although the increased use of chest radiographs by pulmonologists may reflect an older patient population with more comorbidity, the differences in other aspects of care are less easily explained. Allergists were more likely than pulmonologists to encourage the use of peak flowmeters and to provide written treatment plans for their patients. The two subspecialties also appear to differ in their pharmacotherapeutic approaches to asthma, particularly in the use of cromolyn or nedocromil Asthma in Chicago
and inhaled steroids for patients $ 5 years with moderate persistent asthma. The effect of these differences in the management of persons with asthma is not known. The physicians in these two subspecialties appear to represent key leadership in professional education about asthma. Nearly half of the sampled asthma specialists had participated in the development of hospital-based asthma programs, and almost two thirds had given a formal talk or presentation on asthma during the past year. However, the selected practice differences in asthma care between these two specialty groups could potentially confuse the key messages about asthma care that are sent out to the Chicago community. It is also not known how well the asthma specialists in this community are serving in the role of local professional educators of appropriate asthma care.12 As for managed care, nearly three quarters of the specialists reported that their patients experienced barriers in obtaining a referral from their managed care organization. It has been well argued that appropriate access to specialty care is essential to achieve optimal clinical outcomes for many health conditions.13 For asthma, many studies suggest that outcomes are improved with appropriate access to specialty care.3,6,7,14,15 The high frequency of barriers to asthma specialists reported in this survey highlights an issue of community concern. Addressing and solving this concern could lead to community-wide asthma improvements. Several limitations of this study should be noted. As with any self-reported data, respondents may have reported what they believe to be acceptable, instead of their actual practice. The age of the patients treated may also affect some aspects of care. The number of pediatric pulmonologists in the sample (and in the AMA Masterfile) was small; therefore, it is likely that, as a group, the pulmonologists in the sample treat older patients than the allergists. For this reason, in data analysis of items that were specific for children , 5 years, respondents were excluded if they indicated they did not see children in that age group. The items used in the questionnaire did not distinguish between care for children $ 5 years and care for adults. However, for many aspects of asthma care (eg, use of peak flow measurements, spirometry, written treatment plans, and allergy evaluation) the NAEPP guidelines also do not distinguish recommendations between older children and adults. Lastly, it should be recognized that the asthma care delivered by Chicago-area specialists is not necessarily reflective of specialty care in other communities or geographic areas. There are also some key strengths to this communitybased survey of self-reported care to counterbalance the limitations of this report. Although the information gained from this survey may not be generalizable nationwide, it does represent the views of caregivers of a United States community of . 8 million persons and . 300 asthma specialists. In this respect, the survey results provide a baseline from which specialists can begin to explore asthma care issues of local and perhaps regional or national interest. The data could also be used as a benchmark for similar studies in other communities.
Conclusion To our knowledge, this survey provides the only examination of the self-reported views of different subspecialties about the care of persons with asthma. It is hoped that the information from this community-based survey will catalyze discussions among the Chicago-area asthma specialists as to how they might envision improving asthma care in their community. ACKNOWLEDGMENT: We would like to thank the following advisors for their thoughtful review of the survey instrument: Javeid Akhter, MD, Donald Aaronson, MD, David Chudwin, MD, William Clapp, MD, Paul Detjan, MD, Lucille Lester, MD, Christopher Olopade, MD, and Michael Ries, MD. We would also like to thank Ms. Robin Wagner for her assistance in manuscript preparation.
Appendix Other members of the CASI team include (in alphabetical order): Claudia Baier, MPH, Steven Daugherty, PhD, Edward Eckenfels, Christopher Lyttle, MA, and Anita Malone, MPH, of Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL; and Michael McDermott, MD, of Cook County Hospital, Chicago, IL.
References 1 National Asthma Education, and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health; 1991. NIH publication 91–3642 2 National Asthma Education, and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH publication 97– 4051 3 Freund DA, Stein J, Hurley R, et al. Specialty difference in the treatment of asthma. J Allergy Clin Immunol 1989; 84:401– 406 4 Wolle JM, Cwi J. Physicians’ prevention-related practice behaviors in treating adult patients with asthma: results of a national survey. J Asthma 1995; 32:131–140 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 6 Nyman JA, Hillson S, Stoner T, et al. Do specialists order too many tests? The case of allergists and pediatric asthma. Ann Allergy Asthma Immunol 1997; 79:496 –502 7 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 8 Weiss KB, Wagener DK. Changing patterns of asthma mortality. JAMA 1990; 264:1683–1687 9 AMA Physician Masterfile. Chicago, IL: American Medical Association, Department of Data Survey, and Planning, Division of Survey, and Data Resources; 1996 10 National Committee for Quality Assurance. Minnesota QARI demonstration project: a focused review of asthma care, a practice setting survey. Internal report. Washington, DC: National Committee for Quality Assurance, 1995 11 Steinwachs DM, Wu A, Skinner EA, et al. Asthma Patient Outcomes Study: baseline survey summary report. BloomingCHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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ton, MN: The Health Outcomes Institute, 1995 12 Squillace SP, Shaughnessy AF, Slawson DC. The allergist as an educator: an evolving relationship between specialty and primary care clinicians. Ann Allergy Asthma Immunol 1996; 77:341–344 13 Kassirer JP. Access to specialty care. N Engl J Med 1994; 331:1151–1153 14 Zeiger RS, Heller S, Mellon M, et al. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol 1991; 87:1160 –1168 15 Stempel DA, Carlson A, Buchner DA. Asthma benchmarking for quality improvement. Ann Allergy Asthma Immunol 1997; 79:517–524
Characteristics of Asthma Care Provided by Hospitals in a Large Metropolitan Area* Results From the Chicago Asthma Surveillance Initiative Evalyn N. Grant, MD; Tao Li, PhD; Christopher S. Lyttle, MA; and Kevin B. Weiss, MD for the Chicago Asthma Surveillance Initiative Project Team†
Introduction: Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes. Methods: A cross-sectional, self-administered survey was mailed to a “key informant” in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997. Results: Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hos*From the Department of Immunology/Microbiology (Dr. Grant), Rush-Presbyterian-St. Luke’s Medical Center; Center for Health Services Research (Drs. Li and Weiss, and Mr. Lyttle), Rush Primary Care Institute, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL. †See Appendix for other members of the CASI Project Team. CASI is funded by a grant from the Otho S.A. Sprague Memorial Institute. Correspondence to: Kevin B. Weiss, MD, Director, Center for Health Services Research, Rush Primary Care Institute, RushPresbyterian-St. Luke’s Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612 162S
pitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care. Conclusion: The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care. (CHEST 1999; 116:162S–167S) Abbreviation: CASI 5 Chicago Asthma Surveillance Initiative
sthma accounts for . 450,000 hospitalizations annuA ally in the United States. These hospital visits have a 1
significant impact on Untied States health-care expenditures, accounting for an estimated $1.6 billion annually.2 Much of the literature in this area is based on the premise that most asthma hospitalizations are preventable. Therefore, these studies focus on characterizing the risk factors leading up to the event.3– 6 Others focus on follow-up care or patient outcomes after discharge.7–9 There have also been studies examining the impact of emergency department practices on the decision to admit10,11 and, more recently, reports on the advantages of standardized care processes— critical pathways—for improving asthma care and reducing costs during hospitalization.12,13 However, there appear to be no studies that have comprehensively examined the overall approaches to asthma care used by hospitals, including bedside care, asthma education activities, asthma quality improvement projects, and asthma outreach services. The purpose of this study is to characterize the extent to which hospitals in the Chicago area have implemented various types of asthma-specific health-care delivery processes. These characteristics are of particular interest in light of the disproportionately high rate of asthma mortality in this large metropolitan community.14 Asthma in Chicago
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rates of hospitalization of children really mean? N Engl J Med 1989; 320:1200 –1211 Lenfant C, Hurd SS. Special report: National Asthma Education Program. Chest 1990; 98:226 –227 National Asthma Education, and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 1991. NIH publication 91–3642 Burt CW, Knapp DE. Ambulatory care visits for asthma: United States, 1993–1994; Hyattsville, MD: National Center for Health Statistics; 1996. Advance data from vital and health statistics No. 277 Crain EF, Weiss KB, Fagan MJ. Pediatric asthma care in US emergency departments. Arch Pediatr Adolesc Med 1995; 149:893–901 Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management. Arch Intern Med 1997; 157: 1193–1200 Gourgoulianis KI, Hamos B, Christou K, et al. Prescription of medications by primary care physicians in the light of asthma guidelines. Respiration 1998; 65:18 –20 Wolle JM, Cwi J. Physicians’ prevention-related practice behaviors in treating adult patients with asthma: results of a national survey. J Asthma 1995; 32:131–140 National Committee for Quality Assurance. Minnesota QARI demonstration project: a focused review of asthma care, a practice setting survey. Internal report. Washington, DC: National Committee for Quality Assurance; 1995 Steinwachs DM, Wu A, Skinner EA, et al. Asthma Patient Outcomes Study: baseline survey summary report. Bloomington, MN: The Health Outcomes Institute, 1995 National Asthma Education, and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH publication 97– 4051 AMA Physician Masterfile. Chicago, IL: American Medical Association, Department of Data Survey, and Planning, Division of Survey, and Data Resources; 1996 Eggleston PA, Malveaux FJ, Butz AM, et al. Medications used by children with asthma living in the inner city. Pediatrics 1998; 101:349 –354 Stempel DA, Durcannin-Robbins JF, Hedblom EC, et al. Drug utilization evaluation identifies costs associated with high use of beta-adrenergic agonists. Ann Allergy Asthma Immunol 1996; 76:153–158 American Academy of Allergy, Asthma, and Immunology. Pediatric asthma: promoting best practice; guide to managing asthma in children. J Allergy Clin Immunol Monograph, Milwaukee, WI (in press) Warner JO, Naspitz CK, Cropp GJA, eds. Third International Pediatric Consensus: Statement on the Management of Childhood Asthma. Pediatr Pulmonol 1998; 25:1–17 Lieu TA, Quesenberry CP, Capra AM, et al. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics 1997; 100:334 –341 Inouye J, Kristopatis R, Stone E, et al. Physicians’ changing attitudes toward guidelines. J Gen Intern Med 1998; 13:324 – 326 Picken HA, Greenfield S, Teres D, et al. Effect of local standards on the implementation of national guidelines for asthma: primary care agreement with national asthma guidelines. J Gen Intern Med 1998; 13:659 – 663
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Asthma Care Practices, Perceptions, and Beliefs of Chicago-Area Asthma Specialists* James N. Moy, MD; Evalyn N. Grant, MD; Karen Turner-Roan, MPH; Tao Li, PhD; and Kevin B. Weiss, MD; for the Chicago Asthma Surveillance Initiative Project Team†
Introduction: Few studies have closely explored how well physicians who consider themselves specialists in asthma adhere to national guideline recommendations for the diagnosis and treatment of asthma. The purpose of this study is to characterize current knowledge, attitudes, beliefs, and self-reported treatment practices of the asthma specialists working in one large metropolitan area. Methods: In 1997, a cross-sectional survey was mailed to asthma specialists (allergists or pulmonologists) engaged in direct patient care with a practice location in the Chicago area (Cook County or one of the five surrounding counties). An approximately 50% random sample of asthma specialists was surveyed. The survey included items on (1) asthma diagnosis; (2) clinical monitoring of asthma patients; (3) pharmacologic and nonpharmacologic asthma treatment; (4) opinions and beliefs about asthma treatment options and reasons for referrals; (5) involvement in continuing medical education; (6) experiences with managed care; (7) use of asthma practice guidelines; (8) demographic information about the respondents; and (9) characteristics of the practice settings. Results: A total of 113 eligible surveys were returned (response rate, 72.0%). Ninety-nine percent of the respondents indicated they would prescribe inhaled corticosteroids for patients > 5 years old with moderate persistent asthma, and 85.5% would prescribe them for patients < 5 years old. The respondents reported that 71.2% of their patients with moderate or severe persistent asthma were routinely given written treatment plans. The use of these plans was reported more frequently by allergists than pulmonologists (77.6% vs 58.9%, p 5 0.01). Nearly half of the respondents were involved in the development of hospital-based asthma programs; fewer (14.9%) *From the Department of Pediatrics, Cook County Children’s Hospital (Dr. Moy), the Department of Immunology/Microbiology (Dr. Grant), and the Center for Health Services Research, Rush Primary Care Institute (Ms. Turner-Roan, Drs. Li, and Weiss), Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL. †See Appendix for other members of the CASI Project Team. CASI is funded by a grant from the Otho S.A. Sprague Memorial Institute. Correspondence to: Kevin B. Weiss, MD, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke’s Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612 Asthma in Chicago
were involved in developing asthma programs for managed care organizations. A majority (63.4%) of the physicians had given a formal professional education presentation on asthma in the past year. A majority of the respondents who care for patients under managed care contracts reported that these patients have encountered barriers to access in seeking specialty care. Conclusion: The results suggest that asthma specialists in the Chicago area are providing asthma care that is, in many ways, consistent with national guidelines. However, there are also important differences in care that are not consistent with the guideline recommendations. Perhaps even more notable are differences in reported asthma care between the two subspecialty groups of allergists and pulmonologists. The effect of these differences on the management of persons with asthma is not known. It is hoped that information from this community-based survey will serve to catalyze discussions among Chicago-area asthma specialists as to how they might envision improving care for persons with asthma in their community. (CHEST 1999; 116:154S–162S) Abbreviations: AMA 5 American Medical Association; CASI 5 Chicago Asthma Surveillance Initiative; NAEPP 5 National Asthma Education and Prevention Program is often assumed that much of the leadership for defining I toptimal medical care in the primary care setting emerges
from the knowledge, attitudes, beliefs, and actual practice patterns of medical care subspecialists. Subspecialty wisdom is conveyed to the primary care physicians through a variety of mechanisms, such as consultation, formal educational sessions, and scholarly publications. More recently, there has been extensive subspecialty involvement in the development and dissemination of clinical practice guidelines. And yet, there is limited published information on the normative practice patterns of subspecialists, even for many common chronic conditions. Asthma is one of the common chronic conditions for which there has been substantive subspecialty input into nationally accepted clinical practice guidelines. Asthma subspecialists were instrumental in both the design and dissemination of the expert panel report, “Guidelines for the Diagnosis and Management of Asthma,” of the National Asthma Education and Prevention Program (NAEPP), first published in 19911 and subsequently revised in 1997.2 However, to date, few studies have closely explored how well physicians who consider themselves specialists in asthma care adhere to these guidelines.3–7 None of these studies examine the similarities or differences in reported care between the two different subspecialties of allergy and pulmonology. Yet collectively, these two groups constitute nearly all physicians who are commonly considered to be asthma specialists. Chicago has one of the highest asthma mortality rates in the nation.8 It has been suggested that quality of and access to health care are key factors relating to this disproportionate mortality. Therefore, within the Chicago
community, there is a large concern over the quality of care provided by its physicians. The purpose of this study was to characterize the current knowledge, attitudes, beliefs, and self-reported practices of asthma specialists— both allergists and pulmonologists—working in the Chicago metropolitan area. A secondary purpose was to examine differences between allergists and pulmonologists for several key aspects of asthma care.
Materials and Methods A cross-sectional written survey was used to assess asthma care among Chicago-area asthma specialists during 1997. Study Population Chicago-area asthma specialists were identified from the American Medical Association (AMA) 1995 Masterfile,9 which contains names and professional information on all practicing physicians in the United States. Physicians meeting the following criteria were identified: (1) engaged in direct patient care; (2) practice location in Cook, Lake, Du Page, McHenry, Kane, or Will counties, IL; and (3) primary or secondary specialty of allergy, allergy and immunology, allergy and immunology/diagnostic laboratory immunology, pulmonary diseases, critical care medicine, or pediatric pulmonology. Survey Instrument A self-administered survey instrument was constructed on the basis of existing surveys developed by the National Heart, Lung, and Blood Institute,4 the Quality Assurance Reform Initiative project of the National Committee on Quality Assurance,10 and the Managed Health Care Association.11 An advisory panel of local allergists and pulmonologists reviewed the survey items and content areas. The survey was revised on the basis of panel recommendations to include additional questions reflecting new content areas. The final survey instrument consisted of 174 items covering the following content areas of asthma care: (1) diagnosis; (2) clinical monitoring; (3) pharmacologic and nonpharmacologic treatment; (4) opinions and beliefs about treatment options and reasons for referrals; (5) involvement in continuing medical education; (6) experiences with managed care; (7) use of asthma practice guidelines; (8) respondent demographics; and (9) characteristics of practice settings. Sampling Methods From the AMA Masterfile, 364 specialty physicians were identified. The 364 listings were subsequently sorted into one of three groups: group 1 consisted of 244 physicians with a primary specialty of allergy, pulmonology, pediatric pulmonology, or critical care medicine; group 2 consisted of 109 physicians with a secondary specialty of allergy, pulmonology, pediatric pulmonology, or critical care medicine; and group 3 consisted of 11 physicians with a combination of either allergy, pulmonology, pediatric pulmonology, and critical care medicine as their primary and secondary specialty. The survey sample included all 11 physicians in group 3 and 50% of the physicians in groups 1 and 2. Physicians were considered ineligible if they had retired, were deceased, or had moved their practice outside of the six-county study area. Survey Administration The survey was mailed to the sample population along with a cover letter and a postage-paid return envelope. The physicians CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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were asked to return their surveys by mail or fax. To maximize the response rate, the first mailing was supplemented by additional mailings and telephone calls to nonrespondents. Data Analysis Completed surveys were excluded from this analysis if the respondent reported that asthma patients constitute , 1% of their practice. For the survey items that inquired about care for children , 5 years old, responses from physicians who did not provide care for patients in that age group were also excluded from the analysis. For the comparisons between pulmonologists and allergists, the respondents were classified by specialty on the basis of their response to the question, “How would you best describe your current medical specialty?” Respondents were also asked whether they were Board certified or eligible in each specialty. Those that reported Board certification or eligibility in pulmonary medicine or pediatric pulmonary medicine were classified as pulmonologists. Those that reported Board certification or eligibility in allergy and clinical immunology were classified as allergists. Data analysis was conducted using SAS computer software (SAS Version 6.12; SAS Institute; Cary, NC). When appropriate, tests of significance were performed using x2 or nonparametric analysis of variance. Means are reported with SE. For the purposes of this discussion, the term “very few” is used to describe responses reported by , 20% of the respondents, “minority” refers to 20 to 49%, “majority” refers to 50 to 79%, and “nearly all” refers to 80 to 100%. This project was approved by the Institutional Review Board of Rush-Presbyterian-St. Luke’s Medical Center.
Results Thirty of the 187 physicians in the original sample were ineligible. Of the remaining 157, 113 surveys were returned, for a response rate of 72.0%. Ten surveys were subsequently excluded because the respondents did not identify themselves as either pulmonologists or allergists, leaving 103 available for analysis.
General Characteristics of Physicians and Practices Table 1 displays some of the demographic characteristics of the respondents in comparison to the other
Chicago-area pulmonologists and allergists in the 1995 AMA Masterfile. The sample respondents were similar to the other Chicago-area asthma specialists by specialty distribution, age, sex, years since graduation, United States graduation, and type of practice setting. Two surveys were excluded from additional analysis because the respondents reported that , 1% of their patients had asthma. Of the remaining 101 respondents, 38 (37.6%) identified themselves as pulmonologists and 59 (58.4%) identified themselves as allergists. Four respondents (4.0%) identified themselves as specialists in both pulmonology and allergy. These four were included in the overall analyses, but were excluded from analyses comparing responses of pulmonologists with those of allergists. The respondents estimated that patients with asthma represented an average of 46.5 6 2.4% of their practice, with allergists reporting slightly higher percentages than pulmonologists (49.0 6 0.03% vs 40.0 6 0.04%, respectively; p 5 0.08).
Approach to Evaluation and Monitoring of Asthma Patients The survey examined the respondents’ opinions regarding what percent of patients with newly diagnosed moderate persistent asthma should receive certain diagnostic tests. As seen in Table 2, spirometry was recommended for nearly all patients. The respondents reported that the majority of asthma patients should receive a trial of daily peak flow monitoring, a chest radiograph, and testing for IgE-mediated allergies and that very few patients should require a sputum examination and staining for eosinophilia. The pulmonologists and allergists generally agreed on most items, with two notable exceptions. The first was that pulmonologists indicated that a higher percentage of patients should receive chest radiographs (87.9 6 4.6%) as compared with the allergists’ response (47.5 6 5.2% of
Table 1—Characteristics of CASI Asthma Specialist Survey Respondents Compared With the Chicago-Area Specialists in the 1995 AMA Masterfile* Characteristics Subspecialty‡ Pulmonary medicine, % Allergy and immunology, % Pediatric pulmonary medicine, % Age, yr (mean 6 SEM) Female gender, % Years since medical school graduation, mean (SE) United States graduate, % Type of practice Office-based, % Hospital-based, % Percentage of asthma patients in practice, mean (SE)
Respondents, n 5 103
AMA Masterfile†, n 5 261
p Value
35.9 61.2 2.9 51.9 (1.0) 28.2 26.4 (10.3) 66.0
36.5 51.0 3.5 52.1 (0.8) 23.8 26.3 (12.4) 62.5
0.21
0.88 0.38 0.97 0.50
81.6 5.8 46.5 (2.4)
73.6 8.4 —
0.11 0.40 —
*Based on data reported in the 1995 AMA Masterfile.9 Does not include information on the 10 respondents who were deemed ineligible. †Excluding respondent data. ‡Primary or secondary medical specialty. §Based on survey responses. 156S
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Table 2—Approach to Evaluation and Monitoring of Asthma as Reported by Chicago-Area Specialists* Approaches
All Respondents, n 5 101†
Pulmonologists, n 5 38‡
Allergists, n 5 59‡
p Value
Patients with newly diagnosed moderate persistent asthma who should receive the following diagnostic techniques as part of their evaluation, mean (SE) Spirometry, % 87.9 (2.4) 93.6 (2.5) 84.7 (3.6) 0.07 Chest radiograph, % 61.5 (4.0) 87.9 (4.0) 47.5 (5.2) , 0.01 Skin testing or RAST, % 61.1 (4.0) 20.2 (3.5) 89.3 (2.8) , 0.01 Sinus radiographs or CT, % 30.2 (2.5) 25.9 (3.9) 33.9 (3.3) 0.12 Trial of daily peak flow monitoring, % 69.5 (3.8) 60.2 (6.3) 74.8 (4.8) 0.06 Sputum examinations and stain for eosinophilia, % 12.3 (2.6) 13.1 (4.4) 12.6 (3.5) 0.93 Physicians who order the following diagnostic tests as part of their routine evaluation of patients with moderate or severe asthma Sinus radiographs, % 4.0 5.3 3.5 0.68 CT of the sinuses, % 11.9 5.3 16.9 0.09 MRI of the sinuses, % 0.0 0.0 0.0 — Nasal speculum examination, % 60.2 36.8 78.6 , 0.01 Rhinolaryngoscopy, % 3.0 0.0 5.2 0.25 UGI for GERD, % 4.0 7.9 1.7 0.14 Esophageal pH testing for GERD, % 1.0 0.0 1.7 0.42 Use of peak flow or spirometry Physicians who find home peak flow monitoring to be often useful for 60.0 50.0 65.5 0.13 management of moderate to severe persistent asthma, % Patients $ 5 years with moderate or severe persistent asthma that are 69.3 (3.6) 52.6 (5.8) 79.5 (4.2) , 0.01 prescribed home peak flow monitoring, mean % (SE) Physicians who “often” performed PEFR or PFT for acutely symptomatic 75.0 57.9 84.5 , 0.01 patients, % Physicians who “often” performed PEFR or PFT for asymptomatic 51.0 34.2 60.3 0.01 patients, % *Individual item response rates were . 90% of the sample unless otherwise indicated. RAST 5 radioallergosorbent testing; UGI 5 upper GI series; GERD 5 gastroesophageal reflux disease; PEFR 5 peak expiratory flow rate; PFT 5 pulmonary function tests. †Of the 103 surveys returned, two physicians did not see sufficient numbers of asthma patients to include in the analysis. ‡Four respondents reported themselves as both pulmonologists and allergists and were excluded from the comparisons by specialty type.
patients; p , 0.01). The other notable difference was that the allergists indicated four times as many patients (89.3 6 2.8%) should receive specific IgE allergy testing (radioallergosorbent testing or skin testing) compared with the pulmonologists’ response (20.2 6 3.5% of patients). Table 2 also displays the responses to questions asked about other diagnostic tests for patients with moderate or severe persistent asthma. The specialists reported that, with the exception of the nasal speculum examination, few tests other than those noted above were routinely obtained. When asked about radiographic evaluation of the sinuses, 11.9% of the physicians reported that they routinely ordered CT scans and 4.0% routinely ordered sinus radiographs (p 5 0.04). None of the respondents ordered an MRI of the sinuses as part of their routine examination of persons with moderate or severe asthma. For patients with moderate persistent asthma under good control, 73.3% of the respondents reported scheduling routine visits more frequently than every 6 months; 13.9% indicated they scheduled routine visits less frequently than every 6 months. Very few (7.9%) of the physicians reported that they followed up with office visits only when the patient is symptomatic.
Use of Objective Airway Function Testing The survey also queried the specialists’ opinions on the usefulness of peak flow measurements. As seen in
Table 2, the majority of the respondents indicated that home peak flow monitoring is often useful for patients with moderate-to-severe persistent asthma. On average, the respondents also indicated that the majority of their patients with moderate-to-severe asthma are instructed to monitor peak flow readings at home. In comparing the two types of asthma specialists, the allergists’ patients were more likely to have been prescribed home peak flow monitoring than the pulmonologists’ patients (79.5 6 4.2% vs 52.6 6 5.8%; p , 0.01). The allergists and pulmonologists also differed in their use of objective testing of airway function during an office visit. Overall, 75.0% of the respondents reported performing peak flow measurements or pulmonary function testing “often” for acutely symptomatic patients; by specialty, 84.5% of allergists vs 57.9% of pulmonologists performed these tests “often” (p , 0.01). As for asymptomatic patients, 51.0% of the respondents reported performing these tests “often” during an office visit, and, similar to the acute patient scenario, reported use was higher for allergists than pulmonologists (60.3% vs 34.2%; p 5 0.01). Nearly all (85.3%) the respondents reported that they had a spirometer in their offices, whereas very few (14.9%) reported referring their patients for pulmonary function testing at another hospital, clinic, or asthma specialist. CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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Medications Several of the survey items asked about the types of medications prescribed for patients with mild intermittent, moderate persistent, and severe persistent asthma. Medications Prescribed for Mild Intermittent Asthma: For patients , 5 years old with mild intermittent asthma, nearly all (94.7%) the specialists reported that they were likely to prescribe inhaled b-agonists, and the majority (61.4%) were likely to prescribe cromolyn or nedocromil. Prescription of oral b-agonists (45.6%) and inhaled corticosteroids (30.9%) were reported less frequently. Very few specialists (12.5%) were likely to prescribe theophylline. For patients $ 5 years with mild intermittent asthma, the responses were similar to the younger patients. There were no significant differences in treatment by specialist type for patients with mild intermittent asthma. Medications for Moderate Persistent Asthma: Table 3 characterizes the use of pharmacologic agents in the treatment of persons with moderate persistent asthma. The survey data show that 100% of the respondents were likely to prescribe inhaled b-agonists for patients with
moderate or severe persistent asthma. The respondents were more likely to prescribe oral b-agonists for patients , 5 years of age (36.4%) than for patients $ 5 years (21.5%; p 5 0.05). Ninety-nine percent of the respondents indicated they would prescribe inhaled corticosteroids for patients $ 5 years of age with moderate persistent asthma and 85.5% would prescribe them for patients , 5 years. Forty-five percent of the respondents reported that they were likely to prescribe theophylline for patients $ 5 years of age, whereas 33.3% were likely to prescribe it for patients , 5 years of age. The pulmonologists and allergists generally shared similar opinions on medication management for patients with moderate persistent asthma, with one exception. Nearly twice as many allergists would prescribe the nonsteroidal anti-inflammatory medications, cromolyn or nedocromil, for patients $ 5 years (60.3% of the allergists vs 38.2% of the pulmonologists; p 5 0.04). For children , 5 years of age, 83.9% of the respondents were likely to prescribe cromolyn or nedocromil. Medications Prescribed for Severe Persistent Asthma: For children , 5 years of age with severe persistent
Table 3—Pharmacotherapeutic Practices for Persons With Moderate Asthma as Reported by Chicago-Area Asthma Specialists* Practices
All Respondents, Pulmonologists, Allergists, n 5 101† n 5 38‡ n 5 59‡
p Value
Physicians likely to prescribe the following medications for patients $ 5 yr of age with moderate persistent symptoms Theophylline, % 45.3 37.1 48.2 0.30 Oral b-agonists, % 21.5 19.4 24.1 0.61 Inhaled b-agonists, % 100.0 100.0 100.0 — Systemic steroids, % 37.4 37.1 37.7 0.96 Inhaled steroid, % 99.0 100.0 98.3 0.43 Cromolyn/nedocromil, % 53.1 38.2 60.3 0.04 Physicians likely to prescribe the following medications for patients , 5 yr of age with moderate persistent asthma (n 5 57)§ Theophylline, % 33.3 Oral b-agonists, % 36.4 Inhaled b-agonists, % 100.0 Systemic steroids, % 37.7 Inhaled steroids, % 85.5 Cromolyn/nedocromil, % 83.9 Physicians’ response to the question: “For a patient ($ 5 yr of age) with daily symptoms that respond to tid short-acting inhaled b-agonists as his or her only medication, who is waking up more than twice a month with asthma symptoms, what would you do next?” No change, % 0.0 0.0 0.0 Increase b-agonists, % 1.0 2.6 0.0 0.21 Add theophylline, % 3.0 2.6 3.4 0.83 Add inhaled corticosteroids, % 72.3 71.1 74.6 0.70 Add oral steroids, % 1.0 2.6 0.0 0.21 Add cromolyn/nedocromil, % 9.9 5.3 10.2 0.39 Add inhaled corticosteroids or cromolyn/nedocromil, % 82.2 76.3 84.8 0.30 Add long-acting b-agonists, % 9.9 13.2 8.5 0.50 Other, % 3.0 2.6 3.4 0.83 *Individual item response rates are . 90% of the sample unless otherwise noted. Responses are a percentage of the physicians using each medicine. †Of the 103 surveys returned, two physicians did not see sufficient numbers of asthma patients to include in the analysis. ‡Four respondents reported themselves as both pulmonologists and allergists and were excluded from the comparisons by specialty type. §Physicians who did not provide care for patients , 5 yr of age were excluded from this analysis. Comparisons between allergists and pulmonologists not done for this item because of the low number of pulmonologists providing care for this young age group (n 5 3).
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asthma, the respondents were most likely to prescribe inhaled b-agonists (100.0%), followed by inhaled corticosteroids (98.2%), systemic corticosteroids (89.1%), and cromolyn or nedocromil (69.1%). A minority of the respondents were likely to prescribe theophylline (55.4%) and oral b-agonists (43.4%). For patients $ 5 years of age with severe persistent asthma, the responses were similar to those for the younger patients, with the exceptions that only 48.9% of the physicians reported that they were likely to prescribe cromolyn or nedocromil, but 76.3% were likely to prescribe theophylline. When comparing allergists and pulmonologists, there was only one marginal difference in medication choice for patients with severe persistent asthma. For patients , 5 years with severe persistent asthma, 57.1% of the allergists indicated they would prescribe theophylline, whereas none of the pulmonologists chose theophylline for this age group (p 5 0.05). When asked the question, “For a patient ($ 5 years) with daily symptoms that respond to three times per day short-acting inhaled b-agonists as his or her only medication who is waking up more than twice a month with asthma symptoms, what would you do next?” 82.2% of the respondents indicated they would add inhaled anti-inflammatory medications (72.3% specified inhaled corticosteroids and 9.9% specified cromolyn or nedocromil). Nearly 10% of the respondents reported that they would add a long-acting b-agonist instead of anti-inflammatory medications. There were no significant differences in responses between the allergists and pulmonologists with regard to this question.
Perceptions of the Safety of Inhaled Corticosteroids When asked about the safety of long-term use of inhaled corticosteroids at standard doses, the majority (57.0%) of the respondents answered “very safe.” A minority (41.0%) answered “safe,” and 2.0% were “uncertain.” For patients , 5 years, a minority of the respondents perceived their use as “very safe” (31.8%) or “safe” (44.7%). Approximately 21% of the respondents were unsure of the safety, and 2.4% answered “unsafe.”
Nonpharmacologic Management of Asthma Sixty-six percent of the physicians (98.3% of the allergists and 15.8% of the pulmonologists; p , 0.001) reported using immunotherapy for patients with moderate asthma. On average, these physicians used immunotherapy on 38.0 6 3.2% of their patients with moderate asthma. For all respondents, the most commonly reported environmental control measures recommended for patients with stable moderate or severe asthma were avoidance of household tobacco smoke (97.0%) and removal of pets from the bedroom (87.0%). Recommended use of mattress and pillow covers was reported by 68.3% of the respondents. Only a minority routinely recommended high-efficiency particulate air filters (35.6%) or dehumidification. Routine cleaning of ductwork and avoidance of exercise and physical activity were recommended rarely.
Approach to Asthma Education Regarding asthma patient education, only 11.0% of the respondents reported that they referred their patients to a formal asthma education program. Instead, 87.1% reported that they conducted informal educational programs in their offices. One fourth of the physicians reported that their practices had a dedicated asthma case manager for patients with difficult-to-control asthma. Of the case managers, 66.7% were reported to be registered nurses. Nineteen percent of the physicians reported that their practice had a dedicated nonphysician health educator who delivered formal asthma education. Of the health educators, 65.0% were reported to be registered nurses.
Opinions About Referrals to Asthma Specialists The specialists were asked the question, “which of the following should prompt a primary care physician to refer patients to an asthma specialist?” Nearly all reported that the following should prompt a consultation: a life threatening episode (100.0%), severe persistent asthma (99.0%), continued symptoms on multiple medications (99.0%), hospitalization for asthma (92.1%), and diagnosis in children # 3 years (84.6%). Most of the specialists (59.4%) reported that an emergency department visit was an indication for consultation, and 29.7% viewed a diagnosis of mild persistent asthma as a reason for consultation.
Other Aspects of Asthma Management When asked about asthma practice guidelines, very few of the physicians responded that they did not follow any type of asthma practice guidelines (Table 4). Of the various types of asthma guidelines available, 89.0% of the respondents indicated that they followed the NAEPP guidelines. On average, the respondents reported that 71.2 6 3.6% of their patients with moderate or severe persistent asthma were routinely given written treatment plans. Overall, more allergists than pulmonologists reported use of written treatment plans (77.6 6 4.4% vs 58.9 6 6.5%; p 5 0.01). All of the physicians indicated that patients had 24-h telephone access to their practice. The specialists were asked what they would do if a patient called for an acute but nonlife-threatening asthma exacerbation. Sixty-eight percent of the asthma specialists reported that they would provide a same-day appointment at the office, and very few reported they would instruct the patient to go to the emergency department (14.0%).
Managed Care Issues Ninety-two percent of the respondents reported that managed care patients were a part of their practices. As seen in Figure 1, a majority of the respondents indicated that their patients with managed care coverage have encountered barriers to access in seeking specialty care. More than half of the physicians reported being contacted by either a managed care organization or pharmaceutical CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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Table 4 —Asthma Quality of Care Practice Issues as Reported by Chicago-Area Asthma Specialists* Practice Issues Physicians using the following asthma care practice guidelines NAEPP, % Global Initiative for Asthma, % International Consensus Report, % Other, % Do not use guidelines, % Physicians involved in the development of asthma programs In hospitals, % In managed care organizations, % Other, % Physicians who have given a formal talk or presentation on asthma in the past year, %
All Respondents, n 5 101†
Pulmonologists, n 5 38‡
Allergists, n 5 59‡
p Value
89.0 29.0 25.0 7.0 8.0
89.9 15.8 13.2 7.9 10.5
89.7 36.2 31.0 6.9 6.9
0.98 0.03 0.05 0.85 0.53
46.5 14.9 5.9 63.4
44.7 18.4 0.0 63.2
44.1 13.6 10.2 61.0
0.95 0.52 0.04 0.83
*Individual item response rates were . 90% of the sample unless otherwise noted. NAEPP 5 National Asthma Education and Prevention Program. †Of the 103 surveys returned, two physicians did not see sufficient numbers of asthma patients to include in the analysis. ‡Four respondents reported themselves as both pulmonologists and allergists, and were excluded from the comparisons by specialty type.
benefits manager about their prescribing practices for asthma patients. Figure 1 also shows that significantly more allergists than pulmonologists answered yes to both of these questions.
Asthma Specialists as Educators and Opinion Leaders The respondents were questioned about their involvement in asthma management programs, such as critical pathways, practice guidelines and parameters, or diseasemanagement programs. Nearly half of the respondents were involved in the development of hospital-based programs; few (14.9%) were involved in developing asthma programs for managed care organizations (Table 4). A majority of the physicians had given a formal presentation on asthma in the past year.
Discussion The results of this survey suggest that asthma specialists in the Chicago area report that they are providing asthma
Figure 1. Frequency of specialty physician reports of selected asthma-related issues in managed care. 160S
care that is in many ways consistent with the NAEPP guidelines, particularly in areas such as the following: frequent use of spirometry for the initial diagnosis and monitoring of persons with moderate persistent asthma, prescribing of anti-inflammatory medications for persons with moderate persistent asthma, and providing patients with written action plans. However, the survey data also demonstrate important differences in specialists’ care vs the NAEPP guideline recommendations. For example, although the survey data indicate overall frequent use of peak flow or spirometry for monitoring patients, there was a clear tendency for the specialists to use these tools much more commonly for acutely symptomatic patients than for asymptomatic patients. The specialists also reported moderate use of inhaled steroids for patients with mild intermittent asthma. These routine asthma care practice patterns, although inconsistent with guideline recommendations, do not, in and of themselves, suggest poor clinical care. Rather, they present issues for further discussion on what might be considered normative specialty care. The inconsistencies in asthma care between the specialist groups also have the potential to deliver confusing messages to primary-care physicians and their patients. Some of these differences, such as higher use of immunotherapy by allergists, are not surprising. However, differences in the use of diagnostic imaging (eg, chest and sinus radiographs) and testing for allergen sensitivity (either by skin prick or radioallergosorbent test) are of greater concern. Although the increased use of chest radiographs by pulmonologists may reflect an older patient population with more comorbidity, the differences in other aspects of care are less easily explained. Allergists were more likely than pulmonologists to encourage the use of peak flowmeters and to provide written treatment plans for their patients. The two subspecialties also appear to differ in their pharmacotherapeutic approaches to asthma, particularly in the use of cromolyn or nedocromil Asthma in Chicago
and inhaled steroids for patients $ 5 years with moderate persistent asthma. The effect of these differences in the management of persons with asthma is not known. The physicians in these two subspecialties appear to represent key leadership in professional education about asthma. Nearly half of the sampled asthma specialists had participated in the development of hospital-based asthma programs, and almost two thirds had given a formal talk or presentation on asthma during the past year. However, the selected practice differences in asthma care between these two specialty groups could potentially confuse the key messages about asthma care that are sent out to the Chicago community. It is also not known how well the asthma specialists in this community are serving in the role of local professional educators of appropriate asthma care.12 As for managed care, nearly three quarters of the specialists reported that their patients experienced barriers in obtaining a referral from their managed care organization. It has been well argued that appropriate access to specialty care is essential to achieve optimal clinical outcomes for many health conditions.13 For asthma, many studies suggest that outcomes are improved with appropriate access to specialty care.3,6,7,14,15 The high frequency of barriers to asthma specialists reported in this survey highlights an issue of community concern. Addressing and solving this concern could lead to community-wide asthma improvements. Several limitations of this study should be noted. As with any self-reported data, respondents may have reported what they believe to be acceptable, instead of their actual practice. The age of the patients treated may also affect some aspects of care. The number of pediatric pulmonologists in the sample (and in the AMA Masterfile) was small; therefore, it is likely that, as a group, the pulmonologists in the sample treat older patients than the allergists. For this reason, in data analysis of items that were specific for children , 5 years, respondents were excluded if they indicated they did not see children in that age group. The items used in the questionnaire did not distinguish between care for children $ 5 years and care for adults. However, for many aspects of asthma care (eg, use of peak flow measurements, spirometry, written treatment plans, and allergy evaluation) the NAEPP guidelines also do not distinguish recommendations between older children and adults. Lastly, it should be recognized that the asthma care delivered by Chicago-area specialists is not necessarily reflective of specialty care in other communities or geographic areas. There are also some key strengths to this communitybased survey of self-reported care to counterbalance the limitations of this report. Although the information gained from this survey may not be generalizable nationwide, it does represent the views of caregivers of a United States community of . 8 million persons and . 300 asthma specialists. In this respect, the survey results provide a baseline from which specialists can begin to explore asthma care issues of local and perhaps regional or national interest. The data could also be used as a benchmark for similar studies in other communities.
Conclusion To our knowledge, this survey provides the only examination of the self-reported views of different subspecialties about the care of persons with asthma. It is hoped that the information from this community-based survey will catalyze discussions among the Chicago-area asthma specialists as to how they might envision improving asthma care in their community. ACKNOWLEDGMENT: We would like to thank the following advisors for their thoughtful review of the survey instrument: Javeid Akhter, MD, Donald Aaronson, MD, David Chudwin, MD, William Clapp, MD, Paul Detjan, MD, Lucille Lester, MD, Christopher Olopade, MD, and Michael Ries, MD. We would also like to thank Ms. Robin Wagner for her assistance in manuscript preparation.
Appendix Other members of the CASI team include (in alphabetical order): Claudia Baier, MPH, Steven Daugherty, PhD, Edward Eckenfels, Christopher Lyttle, MA, and Anita Malone, MPH, of Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL; and Michael McDermott, MD, of Cook County Hospital, Chicago, IL.
References 1 National Asthma Education, and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health; 1991. NIH publication 91–3642 2 National Asthma Education, and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH publication 97– 4051 3 Freund DA, Stein J, Hurley R, et al. Specialty difference in the treatment of asthma. J Allergy Clin Immunol 1989; 84:401– 406 4 Wolle JM, Cwi J. Physicians’ prevention-related practice behaviors in treating adult patients with asthma: results of a national survey. J Asthma 1995; 32:131–140 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 6 Nyman JA, Hillson S, Stoner T, et al. Do specialists order too many tests? The case of allergists and pediatric asthma. Ann Allergy Asthma Immunol 1997; 79:496 –502 7 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 8 Weiss KB, Wagener DK. Changing patterns of asthma mortality. JAMA 1990; 264:1683–1687 9 AMA Physician Masterfile. Chicago, IL: American Medical Association, Department of Data Survey, and Planning, Division of Survey, and Data Resources; 1996 10 National Committee for Quality Assurance. Minnesota QARI demonstration project: a focused review of asthma care, a practice setting survey. Internal report. Washington, DC: National Committee for Quality Assurance, 1995 11 Steinwachs DM, Wu A, Skinner EA, et al. Asthma Patient Outcomes Study: baseline survey summary report. BloomingCHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
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ton, MN: The Health Outcomes Institute, 1995 12 Squillace SP, Shaughnessy AF, Slawson DC. The allergist as an educator: an evolving relationship between specialty and primary care clinicians. Ann Allergy Asthma Immunol 1996; 77:341–344 13 Kassirer JP. Access to specialty care. N Engl J Med 1994; 331:1151–1153 14 Zeiger RS, Heller S, Mellon M, et al. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol 1991; 87:1160 –1168 15 Stempel DA, Carlson A, Buchner DA. Asthma benchmarking for quality improvement. Ann Allergy Asthma Immunol 1997; 79:517–524
Characteristics of Asthma Care Provided by Hospitals in a Large Metropolitan Area* Results From the Chicago Asthma Surveillance Initiative Evalyn N. Grant, MD; Tao Li, PhD; Christopher S. Lyttle, MA; and Kevin B. Weiss, MD for the Chicago Asthma Surveillance Initiative Project Team†
Introduction: Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes. Methods: A cross-sectional, self-administered survey was mailed to a “key informant” in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997. Results: Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hos*From the Department of Immunology/Microbiology (Dr. Grant), Rush-Presbyterian-St. Luke’s Medical Center; Center for Health Services Research (Drs. Li and Weiss, and Mr. Lyttle), Rush Primary Care Institute, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL. †See Appendix for other members of the CASI Project Team. CASI is funded by a grant from the Otho S.A. Sprague Memorial Institute. Correspondence to: Kevin B. Weiss, MD, Director, Center for Health Services Research, Rush Primary Care Institute, RushPresbyterian-St. Luke’s Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612 162S
pitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care. Conclusion: The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care. (CHEST 1999; 116:162S–167S) Abbreviation: CASI 5 Chicago Asthma Surveillance Initiative
sthma accounts for . 450,000 hospitalizations annuA ally in the United States. These hospital visits have a 1
significant impact on Untied States health-care expenditures, accounting for an estimated $1.6 billion annually.2 Much of the literature in this area is based on the premise that most asthma hospitalizations are preventable. Therefore, these studies focus on characterizing the risk factors leading up to the event.3– 6 Others focus on follow-up care or patient outcomes after discharge.7–9 There have also been studies examining the impact of emergency department practices on the decision to admit10,11 and, more recently, reports on the advantages of standardized care processes— critical pathways—for improving asthma care and reducing costs during hospitalization.12,13 However, there appear to be no studies that have comprehensively examined the overall approaches to asthma care used by hospitals, including bedside care, asthma education activities, asthma quality improvement projects, and asthma outreach services. The purpose of this study is to characterize the extent to which hospitals in the Chicago area have implemented various types of asthma-specific health-care delivery processes. These characteristics are of particular interest in light of the disproportionately high rate of asthma mortality in this large metropolitan community.14 Asthma in Chicago