- Email: [email protected]
National Heart, Lung, and Blood Institute Guidelines and Asthma Management Practices Among Inner-City Pediatric Primary Care Providers
Original Research ASTHMA
National Heart, Lung, and Blood Institute Guidelines and Asthma Management Practices Among InnerCity Pediatric Primary Care Providers* Deepa Rastogi, MD; Ashita Shetty, MD; Richard Neugebauer, PhD; and Anantha Harijith, MD
Background and objective: Most surveys of pediatric outpatient asthma management obtain information from parents and caregivers. Studies based on surveys of primary health-care providers are sparse. Suboptimal outpatient management may play a role in the high hospitalization rates among inner-city asthmatic children. Asthma management practices were compared between hospital-based and community-based primary care providers (PCPs). Adherence to National Heart, Lung, and Blood Institute (NHLBI) guidelines was evaluated, along with practices not clearly defined in the guidelines such as use of oral cough medicines and albuterol suspension. Design/methods: An 8-point questionnaire was administered to 48 community-based and 32 hospital-based PCPs practicing in inner-city neighborhoods. The questionnaire addressed three “positive” practices (classification of asthma severity, use of asthma action plan, and use of a spacer) and three “negative” practices (use of cough syrup, use of albuterol suspension, and preferential use of leukotriene modifiers instead of inhaled corticosteroids as the first line of preventive therapy). Response options were as follows: never, rarely, sometimes, and always, scored from 0 to 3. The two physician groups were compared on score means for the positive and negative practices using a t test with statistical significance set at p < 0.05. Results: Overall, the rate of adherence to the positive practices was high, with no significant difference between the two groups. Negative practices, while present in both the groups, were reported significantly more often by the community-based group, particularly the use of cough suppressants and albuterol suspension. Conclusions: Greater emphasis is needed to increase the awareness among PCPs of the NHLBI guideline recommendations, as suboptimal outpatient asthma management may contribute to the disproportionately higher hospitalization rates among inner-city asthmatic children. Clarification on the use of potentially harmful medications and those of doubtful value need to be incorporated in the guidelines. The extent to which these negative practices contribute to the elevated pediatric hospitalization rates warrants further investigation. (CHEST 2006; 129:619 – 623) Key words: asthma management; inner city; National Heart, Lung, and Blood Institute guidelines; pediatrics; primary care provider Abbreviations: NHLBI ⫽ National Heart, Lung, and Blood Institute; NYC ⫽ New York City; NYSDOH ⫽ New York State Department of Health; PCP ⫽ primary care provider
is a chronic medical condition with inA sthma creasing prevalence in the United States over the past decade. The increase has been disproportionately higher in the inner-city ethnic minority populations and among children more than among adults.1 www.chestjournal.org
In 1991, national guidelines were developed by the National Heart, Lung, and Blood Institute (NHLBI) in an attempt to streamline the diagnosis and management of asthma.2 The guidelines were revised in 1997 with greater focus on the primary role of inflammation in the pathogenesis of asthma, CHEST / 129 / 3 / MARCH, 2006
619
thus emphasizing the use of inhaled steroids as the first line of preventive therapy.3 The guidelines offer an evidence-based review of current therapeutic options available and recommend a stepwise approach to asthma management. Despite the availability of these guidelines for the past 14 years, the recommended asthma management does not appear to be as widely practiced. While questionnaires administered to families with children with asthma suggest that practices such as prescription of a spacer and filling an asthma action plan remain far less than expected,4 – 6 few studies have directly addressed asthma management practices of the primary care providers (PCPs). Doerschug et al7 evaluated asthma knowledge among 108 physicians including asthma specialists, internists, family medicine physicians, and specialty fellows, as well as residents at a university hospital. Although the specialists scored higher than others in total score, deficits were noted among all physician groups regarding understanding of the NHLBI guidelines. Janson and Weiss8 surveyed a national random sample of 512 physicians, including generalists, as well as specialists, providing care to asthmatics. They reported significant differences in practices between specialists and generalists, with specialists using preventive medications more regularly but continued suboptimal application of guidelines by both the groups. In a metaanalysis, Crim9 reviewed six studies on asthma management by physicians and noted a lack of consistent and widespread use of the guidelines. While physician compliance with the NHLBI guidelines was in general found to be unsatisfactory in these studies, none of these investigations specifically addressed the asthma management practices in an inner-city area. Also, to the best of our knowledge, prescription practices among providers of medications that are potentially harmful to asthmatics, such as cough suppressants, has not been evaluated to date. The prevalence of asthma in New York City (NYC) is 29% higher than the national average. In 2000, hospitalization rates for NYC asthmatic children (6 per 1,000) are nearly double the rates for the United States as a whole (3.4 per 1,000).10 This excess *From the Department of Pediatrics (Drs. Rastogi, Shetty, and Harijith), Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx; and New York State Psychiatry Institute (Dr. Neugebauer), Columbia University, New York, NY. Manuscript received March 31, 2005; revision accepted June 14, 2005. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Deepa Rastogi, MD, Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY 10467; e-mail: [email protected] 620
suggests either that asthma is more severe in NYC children or their outpatient management is suboptimal, leading to frequent hospitalizations. Disparities also exist within NYC with the pediatric hospitalization rate for asthma being fourfold higher in low socioeconomic neighborhoods as compared with high-income neighborhoods.10 The rate of hospitalization in the South Bronx, an extremely depressed socioeconomic area, is one of the highest (9.2 per 1,000) in the New York metropolitan area. While 20.8% of all children aged 0 to 14 years in NYC reside in the Bronx, they contribute 31.4% of the asthma hospitalizations in the same age group.10 Given this extremely high rate of asthma hospitalization, it becomes imperative to assess the knowledge of asthma management among PCPs caring for this particularly high-risk population. Suboptimal outpatient management of asthma may contribute to the high rate of hospitalizations among the inner-city asthmatic children. To evaluate the management practices of pediatric PCPs, we surveyed these professionals in the three neighborhoods with the highest rates of asthma prevalence and hospitalization in the borough of the Bronx: Crotona-Tremont, HighbridgeMorrisania, and Huntspoint-Mott Haven, hereafter referred to as the “South Bronx.”
Materials and Methods Pediatric PCPs in the South Bronx were identified by the location of their primary practice site in the zip code of interest through the provider directories. A medical resident telephoned the provider, scheduled a visit to the provider’s office, and administered an 8-item questionnaire requiring approximately 5 min to complete. Of the 132 PCPs identified as practicing in the South Bronx, only 90 PCPs were available when approached via telephone or in person. Of these, 10 PCPs refused to participate in the survey. All of the remaining 80 PCPs completed the questionnaire in the resident’s presence. Of the 80 providers, 48 were in the private practice setting and the remaining 32 were affiliated with Bronx-Lebanon Hospital Center, an academic pediatric hospital in the South Bronx. The first questionnaire item sought confirmation regarding the participant’s professional status, ie, physician, nurse practitioner, or physician assistant. The second questionnaire item asked whether the respondent had had access to the NHLBI guidelines in the past 5 years. Of the remaining six items on the questionnaire, three questions inquired about practices promoted by the NHLBI guidelines, such as asthma severity classification at every visit, prescription of a spacer, and giving an asthma action plan to the family (“positive” practices). The other three questions were based on prescription practices of doubtful value or even potentially harmful to an asthmatic, such as use of cough suppressants and oral albuterol suspension as well as preferential use of leukotriene modifiers over inhaled steroids as first-line therapy (“negative” practices). The response options for these six questions were “never” (score 0), “rarely” (score 1), “sometimes” (score 2), and “always” (score 3). Responses were summed for the three positive and Original Research
three negative practices combined and for each of the six items separately. The two groups of practitioners—private practice and Bronx-Lebanon Hospital Center affiliated—were then compared on the means for the three positive practices and the three negative practices and on the means for each of the six items individually. The highest score attainable for either of the two sets of practices was 9; a t test was performed with statistical significance set at p ⬍ 0.05.
Results Of the 48 private practitioners in the community, 3 were nurse practitioners and the others were physicians. Among the 32 providers affiliated with the academic hospital, all were physicians. All providers except one in the hospital-based group stated having had access to the NHLBI guidelines in the past 5 years. The means of the two groups of PCPs— community based, hospital based— on the scores on all three positive items combined as well on the three negative practices combined was compared. Both groups of practitioners reported high adherence to the positive practices combined (Table 1), and the two groups did not differ on level of adherence. By contrast, the two groups differed significantly on the frequency of the negative practices combined, with the community-based group reporting engaging in negative practices more often. The overall finding
Table 1—Asthma Management Practices Among Inner-city Pediatric PCPs* Clinical Practices Overall scores Positive practices Negative practices Positive practices Asthma classification during visit Asthma action plan given to family Spacer prescribed Negative practices Leukotriene modifier used as first line for persistent asthma Use of cough suppressant Use of albuterol suspension
Community Based
Hospital Based
12.72 ⫾ 0.37 7.76 ⫾ 0.18 4.04 ⫾ 0.27
14.16 ⫾ 0.38 7.73 ⫾ 0.27 2.56 ⫾ 0.25‡
2.76 ⫾ 0.11 2.27 ⫾ 0.07 2.72 ⫾ 0.13
2.76 ⫾ 0.14 2.13 ⫾ 0.09 2.83 ⫾ 0.12
1.58 ⫾ 0.13
1.60 ⫾ 0.11
1.34 ⫾ 0.14 1.11 ⫾ 0.08
0.63 ⫾ 0.12‡ 0.33 ⫾ 0.11†
*Data are presented as mean ⫾ SEM. The response options for each question were “never” (score 0), “rarely” (score 1), “sometimes” (score 2), and “always” (score 3). Responses were summed for the three positive and three negative practices combined and for each of the six items separately. The means with SEM were compared for the practices combined and for each of the six items individually. The highest total score attainable for either of the two sets of practices was 9 and for individual practices was 3. High scores for positive practices and low scores for negative practices correlated with good clinical practice. †p ⬍ 0.01. ‡p ⬍ 0.001. www.chestjournal.org
for positive practices was upheld in analyses of each practice separately. Both practitioner groups reported frequent use of each practice, and the two groups did not differ in this respect. However, comparison of individual negative practices disclosed that the overall significant difference between the two groups was confined to prescription of albuterol oral suspension and cough suppressant. Both groups of providers reported preferential use of leukotriene modifier over inhaled corticosteroids as first line of preventive medication for persistent asthma, and there was no significant difference between the two groups in this regard.
Discussion Asthma is the most common chronic medical condition among children, with frequent hospitalizations giving rise to significant health-care expenditure and loss of school days for the child and workdays for the primary caretakers.11 The prevalence of poorly controlled asthma is disproportionately higher among the children residing in innercity neighborhoods.12 While the causes of these elevated asthma hospitalization rates are multifactorial, the quality of outpatient asthma management almost certainly plays a role. The NHLBI guidelines were published in 1991 and modified in 1997 in an attempt to streamline asthma management practices with an emphasis on increasing the awareness among physicians of the importance of appropriate classification of asthma severity to ensure adequate pharmacotherapy. Use of asthma action plans is encouraged to empower the primary caretaker to better manage exacerbations at home, with the aim of avoiding emergency department visits. There is also emphasis on the role of inflammation in the pathophysiology of asthma to encourage the use of inhaled steroids as the first line of management. While the role of antibiotics in acute asthma exacerbation was recently addressed in an update of the guidelines,13 the use of oral albuterol suspension and cough suppressants in the management of asthma is not as clearly defined in the guidelines and remains nebulous. Despite the availability of these guidelines for over a decade, outpatient management of asthma remains suboptimal.4 – 8 This situation may be a consequence of limited access to the guidelines for some PCPs. In their original form, the guidelines are a lengthy document requiring a significant amount of time to read, which is challenging for the time-pressed pediatrician.14 While hospital-based physicians are regularly exposed to updates on disease management practices in a concise manner through interactive CHEST / 129 / 3 / MARCH, 2006
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conferences such as grand rounds, it is more difficult for physicians in the community to be similarly exposed to concise updates. In our sample, it was noted that there was high adherence to the three positive practices selected from the guidelines in both groups. This result suggests strongly that knowledge about these practices has been widely disseminated in different forums among all the practicing providers. Recently the New York State Department of Health (NYSDOH) summarized the guidelines in a fourpage document that was mailed to all the practicing pediatricians in the NYSDOH registry. Also, as part of a Centers for Disease Control and Preventionfunded program at our hospital, the guidelines were obtained from National Institute of Health and distributed among the pediatricians practicing in the above three neighborhoods about 18 months prior to the administration of the questionnaire. The more significant finding of our study was the improper use of medications such as oral albuterol suspension and cough suppressants for wheezing episodes/acute exacerbations in asthmatic children. These two practices were employed extensively and significantly more often among the communitybased physicians as compared to the hospital-based physicians. While the use of cough suppressants has not been addressed clearly in the guidelines and has not been included in the summary document distributed by the NYSDOH, the American Academy of Pediatrics had issued a policy statement15 on the use of cough suppressants, noting that their efficacy was questionable. Accordingly, the policy statement emphasized that, in conditions such as asthma, cystic fibrosis, and bronchopulmonary dysplasia, where inflammation is the predominant underlying pathophysiologic component, cough suppression may adversely affect these patients by promoting pooling of secretions, secondary infections, and hypoxemia.15 While 37.5% of community-based physicians reported prescribing cough suppressants to asthmatic children sometimes or always, only 6.3% of hospital-based physicians reported the same practice. Similarly, the use of oral albuterol suspension has fallen out of favor over the past decade with the availability of better modalities of targeted inhaled drug delivery systems. These include the nebulizer solution and metered-dose inhalers with spacers. Oral albuterol preparations are not recommended for acute asthma exacerbations and have a limited place in chronic asthma management.16 In our study, 35.4% of community-based physicians reported prescribing albuterol sometimes or always, while only 6.2% of hospital-based providers reported prescribing it sometimes. While the practice of prescribing 622
albuterol syrup was infrequent among the hospitalaffiliated PCPs, it remains common among the community based PCPs, possibly due to their lack of more updated information. The third finding of preferential use of leukotrienes as first-line management for asthma in place of inhaled corticosteroids was a common practice among both groups of providers. This result was a surprising finding, as the guidelines clearly state the use of inhaled corticosteroids as the first line of therapy. This element of the guidelines has also been included in the summary document provided by the NYSDOH. While no further clarification was obtained in on this study, we hypothesize that this may be due to the practitioners’ perceptions of better compliance with preventive medications in the oral form as compared to the inhaled form. Maspero et al17 reported that practitioners believe that adherence is better for those medications administered via the oral route as compared to the inhaled route, and it affects their prescribing pattern. Whereas our findings reflect on the knowledge base regarding asthma management of PCPs in an inner-city environment, our study has certain limitations. It was conducted in a restricted geographic area, and findings may not be applicable to other urban settings. The questionnaire was exceptionally brief, so as to minimize refusal rates. Nonetheless, the six practices covered in the questionnaire were cardinal “do’s” and “don’ts” in the management of asthma. Hence, even though the questionnaire was brief, if the PCP did not respond with correct answers to these questions, it was less likely that he/she would be aware of the other finer details of the guidelines. As stated earlier, 132 pediatric PCPs were identified to be practicing in the South Bronx. Of these, 30% were hospital based while 70% were community based. While 80% of hospital-based PCPs were available, only 52% of the community-based PCPs were available when approached for the survey. The final limitation, therefore, concerns the possible bias introduced by the comparatively high unavailability rate. The idea that community-based practitioners less compliant with the NHLBI guidelines were systematically more compliant with our study invitation seems implausible but cannot be ruled out.
Conclusion This study investigated asthma management practices of health-care providers in different health-care settings to identify potentially harmful practices. Our results underscore the urgent need to increase awareness among community-based health-care proOriginal Research
viders about new developments and advances in the asthma field. However, since our study was geographically limited, further study of asthma management practices of pediatric primary care providers in other inner-city areas is required. To what extent suboptimal outpatient asthma management practices among PCPs contributes to the elevated pediatric asthma hospitalization rates in low-income neighborhoods warrants a separate investigation. While recommendations clearly stated in the guidelines and incorporated into summary documents have been followed by providers in varied clinical settings, potentially harmful practices remain common, as they have not been specifically addressed in the guidelines. While the need for greater incorporation of NHLBI guideline recommendations in outpatient asthma management has been highlighted in previous studies,4,5 our study is the first to evaluate the use of potentially harmful medications such as cough suppressants by PCPs caring for asthmatic children. This study highlights the need for an emphasis in the future guidelines not only on practices beneficial for better management of asthma but also on those that can potentially harm the patient or are of doubtful value. Publishing and disseminating summaries of the guidelines, emphasizing the positive practices as well as discouraging the potentially harmful practices, will likely increase better provider adherence to the guidelines. Providers in varied practice settings will have greater access in this summary document, leading to increased incorporation of the guideline recommendations in the outpatient management of asthmatics. This will lead to improved outpatient medical care and potentially decreased hospitalization rates among asthmatic children.
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References 1 Centers for Disease Control and Prevention. Asthma prevalence and control characteristics by race/ethnicity–United States, 2002. MMWR Morb Mortal Wkly Rep 2004; 53:145– 148 2 National Asthma Education and Prevention Program. Expert
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panel report: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institute of Health, 1991 National Heart, Lung, and Blood Institute. Expert panel report 2: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institute of Health, 1997 Warman KL, Silver EJ, McCourt MP, et al. How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? Pediatrics 1999; 103:422– 427 Scarfone RJ, Zorc JJ, Capraro GA. Patient self-management of acute asthma: adherence to national guidelines a decade later. Pediatrics 2001; 108:1332–1338 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 Doerschug KC, Peterson MW, Dayton CS, et al. Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med 1999; 159:1735–1741 Janson S, Weiss K. A national survey of asthma knowledge and practices among specialists and primary care physicians. J Asthma 2004; 41:343–348 Crim C. Clinical practice guidelines vs. actual clinical practice: the asthma paradigm. Chest 2000; 118:62S– 64S Asthma facts. 2nd ed. New York, NY: New York City Dept of Health and Mental Hygiene, 2000 Rabe K, Adachi M, Lai CKW, et al. Worldwide severity and control of asthma in children and adults: the Global Asthma Insights and Reality Surveys. J Allergy Clin Immunol 2004; 114:40 – 47 Aligne CA, Auinger P, Byrd RS, et al. Risk factors for pediatric asthma: contributions of poverty, race, and urban residence. Am J Respir Crit Care Med 2000; 162:873– 877 NAEPP expert panel report: guidelines for the diagnosis and management of asthma; update on selected topics 2002. Bethesda, MD: National Institutes of Health, 2002; Publication No. 02–5075 Barnes P. Asthma guidelines: recommendations versus reality. Respir Med 2004; (Suppl A):S1–S7 American Academy of Pediatrics. Committee on drugs: use of codeine- and dextromethorphan-containing cough remedies in children. Pediatrics 1997; 99:918 –920 Albuterol: drug summary information: MICROMEDEX Healthcare Series integrated index. Available at: www. micromedex/mdx1/mdxcgi/display.exe. Accessed March 14, 2005 Maspero JF, Duenas-Meza E, Volovitz B, et al. Oral montelukast versus inhaled beclomethasone in 6- to 11-year-old children with asthma: results of an open-label extension study evaluating long-term safety, satisfaction, and adherence with therapy. Curr Med Res Opin 2001; 17:96 –104
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National Heart, Lung, and Blood Institute Guidelines and Asthma Management Practices Among InnerCity Pediatric Primary Care Providers* Deepa Rastogi, MD; Ashita Shetty, MD; Richard Neugebauer, PhD; and Anantha Harijith, MD
Background and objective: Most surveys of pediatric outpatient asthma management obtain information from parents and caregivers. Studies based on surveys of primary health-care providers are sparse. Suboptimal outpatient management may play a role in the high hospitalization rates among inner-city asthmatic children. Asthma management practices were compared between hospital-based and community-based primary care providers (PCPs). Adherence to National Heart, Lung, and Blood Institute (NHLBI) guidelines was evaluated, along with practices not clearly defined in the guidelines such as use of oral cough medicines and albuterol suspension. Design/methods: An 8-point questionnaire was administered to 48 community-based and 32 hospital-based PCPs practicing in inner-city neighborhoods. The questionnaire addressed three “positive” practices (classification of asthma severity, use of asthma action plan, and use of a spacer) and three “negative” practices (use of cough syrup, use of albuterol suspension, and preferential use of leukotriene modifiers instead of inhaled corticosteroids as the first line of preventive therapy). Response options were as follows: never, rarely, sometimes, and always, scored from 0 to 3. The two physician groups were compared on score means for the positive and negative practices using a t test with statistical significance set at p < 0.05. Results: Overall, the rate of adherence to the positive practices was high, with no significant difference between the two groups. Negative practices, while present in both the groups, were reported significantly more often by the community-based group, particularly the use of cough suppressants and albuterol suspension. Conclusions: Greater emphasis is needed to increase the awareness among PCPs of the NHLBI guideline recommendations, as suboptimal outpatient asthma management may contribute to the disproportionately higher hospitalization rates among inner-city asthmatic children. Clarification on the use of potentially harmful medications and those of doubtful value need to be incorporated in the guidelines. The extent to which these negative practices contribute to the elevated pediatric hospitalization rates warrants further investigation. (CHEST 2006; 129:619 – 623) Key words: asthma management; inner city; National Heart, Lung, and Blood Institute guidelines; pediatrics; primary care provider Abbreviations: NHLBI ⫽ National Heart, Lung, and Blood Institute; NYC ⫽ New York City; NYSDOH ⫽ New York State Department of Health; PCP ⫽ primary care provider
is a chronic medical condition with inA sthma creasing prevalence in the United States over the past decade. The increase has been disproportionately higher in the inner-city ethnic minority populations and among children more than among adults.1 www.chestjournal.org
In 1991, national guidelines were developed by the National Heart, Lung, and Blood Institute (NHLBI) in an attempt to streamline the diagnosis and management of asthma.2 The guidelines were revised in 1997 with greater focus on the primary role of inflammation in the pathogenesis of asthma, CHEST / 129 / 3 / MARCH, 2006
619
thus emphasizing the use of inhaled steroids as the first line of preventive therapy.3 The guidelines offer an evidence-based review of current therapeutic options available and recommend a stepwise approach to asthma management. Despite the availability of these guidelines for the past 14 years, the recommended asthma management does not appear to be as widely practiced. While questionnaires administered to families with children with asthma suggest that practices such as prescription of a spacer and filling an asthma action plan remain far less than expected,4 – 6 few studies have directly addressed asthma management practices of the primary care providers (PCPs). Doerschug et al7 evaluated asthma knowledge among 108 physicians including asthma specialists, internists, family medicine physicians, and specialty fellows, as well as residents at a university hospital. Although the specialists scored higher than others in total score, deficits were noted among all physician groups regarding understanding of the NHLBI guidelines. Janson and Weiss8 surveyed a national random sample of 512 physicians, including generalists, as well as specialists, providing care to asthmatics. They reported significant differences in practices between specialists and generalists, with specialists using preventive medications more regularly but continued suboptimal application of guidelines by both the groups. In a metaanalysis, Crim9 reviewed six studies on asthma management by physicians and noted a lack of consistent and widespread use of the guidelines. While physician compliance with the NHLBI guidelines was in general found to be unsatisfactory in these studies, none of these investigations specifically addressed the asthma management practices in an inner-city area. Also, to the best of our knowledge, prescription practices among providers of medications that are potentially harmful to asthmatics, such as cough suppressants, has not been evaluated to date. The prevalence of asthma in New York City (NYC) is 29% higher than the national average. In 2000, hospitalization rates for NYC asthmatic children (6 per 1,000) are nearly double the rates for the United States as a whole (3.4 per 1,000).10 This excess *From the Department of Pediatrics (Drs. Rastogi, Shetty, and Harijith), Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx; and New York State Psychiatry Institute (Dr. Neugebauer), Columbia University, New York, NY. Manuscript received March 31, 2005; revision accepted June 14, 2005. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Deepa Rastogi, MD, Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY 10467; e-mail: [email protected] 620
suggests either that asthma is more severe in NYC children or their outpatient management is suboptimal, leading to frequent hospitalizations. Disparities also exist within NYC with the pediatric hospitalization rate for asthma being fourfold higher in low socioeconomic neighborhoods as compared with high-income neighborhoods.10 The rate of hospitalization in the South Bronx, an extremely depressed socioeconomic area, is one of the highest (9.2 per 1,000) in the New York metropolitan area. While 20.8% of all children aged 0 to 14 years in NYC reside in the Bronx, they contribute 31.4% of the asthma hospitalizations in the same age group.10 Given this extremely high rate of asthma hospitalization, it becomes imperative to assess the knowledge of asthma management among PCPs caring for this particularly high-risk population. Suboptimal outpatient management of asthma may contribute to the high rate of hospitalizations among the inner-city asthmatic children. To evaluate the management practices of pediatric PCPs, we surveyed these professionals in the three neighborhoods with the highest rates of asthma prevalence and hospitalization in the borough of the Bronx: Crotona-Tremont, HighbridgeMorrisania, and Huntspoint-Mott Haven, hereafter referred to as the “South Bronx.”
Materials and Methods Pediatric PCPs in the South Bronx were identified by the location of their primary practice site in the zip code of interest through the provider directories. A medical resident telephoned the provider, scheduled a visit to the provider’s office, and administered an 8-item questionnaire requiring approximately 5 min to complete. Of the 132 PCPs identified as practicing in the South Bronx, only 90 PCPs were available when approached via telephone or in person. Of these, 10 PCPs refused to participate in the survey. All of the remaining 80 PCPs completed the questionnaire in the resident’s presence. Of the 80 providers, 48 were in the private practice setting and the remaining 32 were affiliated with Bronx-Lebanon Hospital Center, an academic pediatric hospital in the South Bronx. The first questionnaire item sought confirmation regarding the participant’s professional status, ie, physician, nurse practitioner, or physician assistant. The second questionnaire item asked whether the respondent had had access to the NHLBI guidelines in the past 5 years. Of the remaining six items on the questionnaire, three questions inquired about practices promoted by the NHLBI guidelines, such as asthma severity classification at every visit, prescription of a spacer, and giving an asthma action plan to the family (“positive” practices). The other three questions were based on prescription practices of doubtful value or even potentially harmful to an asthmatic, such as use of cough suppressants and oral albuterol suspension as well as preferential use of leukotriene modifiers over inhaled steroids as first-line therapy (“negative” practices). The response options for these six questions were “never” (score 0), “rarely” (score 1), “sometimes” (score 2), and “always” (score 3). Responses were summed for the three positive and Original Research
three negative practices combined and for each of the six items separately. The two groups of practitioners—private practice and Bronx-Lebanon Hospital Center affiliated—were then compared on the means for the three positive practices and the three negative practices and on the means for each of the six items individually. The highest score attainable for either of the two sets of practices was 9; a t test was performed with statistical significance set at p ⬍ 0.05.
Results Of the 48 private practitioners in the community, 3 were nurse practitioners and the others were physicians. Among the 32 providers affiliated with the academic hospital, all were physicians. All providers except one in the hospital-based group stated having had access to the NHLBI guidelines in the past 5 years. The means of the two groups of PCPs— community based, hospital based— on the scores on all three positive items combined as well on the three negative practices combined was compared. Both groups of practitioners reported high adherence to the positive practices combined (Table 1), and the two groups did not differ on level of adherence. By contrast, the two groups differed significantly on the frequency of the negative practices combined, with the community-based group reporting engaging in negative practices more often. The overall finding
Table 1—Asthma Management Practices Among Inner-city Pediatric PCPs* Clinical Practices Overall scores Positive practices Negative practices Positive practices Asthma classification during visit Asthma action plan given to family Spacer prescribed Negative practices Leukotriene modifier used as first line for persistent asthma Use of cough suppressant Use of albuterol suspension
Community Based
Hospital Based
12.72 ⫾ 0.37 7.76 ⫾ 0.18 4.04 ⫾ 0.27
14.16 ⫾ 0.38 7.73 ⫾ 0.27 2.56 ⫾ 0.25‡
2.76 ⫾ 0.11 2.27 ⫾ 0.07 2.72 ⫾ 0.13
2.76 ⫾ 0.14 2.13 ⫾ 0.09 2.83 ⫾ 0.12
1.58 ⫾ 0.13
1.60 ⫾ 0.11
1.34 ⫾ 0.14 1.11 ⫾ 0.08
0.63 ⫾ 0.12‡ 0.33 ⫾ 0.11†
*Data are presented as mean ⫾ SEM. The response options for each question were “never” (score 0), “rarely” (score 1), “sometimes” (score 2), and “always” (score 3). Responses were summed for the three positive and three negative practices combined and for each of the six items separately. The means with SEM were compared for the practices combined and for each of the six items individually. The highest total score attainable for either of the two sets of practices was 9 and for individual practices was 3. High scores for positive practices and low scores for negative practices correlated with good clinical practice. †p ⬍ 0.01. ‡p ⬍ 0.001. www.chestjournal.org
for positive practices was upheld in analyses of each practice separately. Both practitioner groups reported frequent use of each practice, and the two groups did not differ in this respect. However, comparison of individual negative practices disclosed that the overall significant difference between the two groups was confined to prescription of albuterol oral suspension and cough suppressant. Both groups of providers reported preferential use of leukotriene modifier over inhaled corticosteroids as first line of preventive medication for persistent asthma, and there was no significant difference between the two groups in this regard.
Discussion Asthma is the most common chronic medical condition among children, with frequent hospitalizations giving rise to significant health-care expenditure and loss of school days for the child and workdays for the primary caretakers.11 The prevalence of poorly controlled asthma is disproportionately higher among the children residing in innercity neighborhoods.12 While the causes of these elevated asthma hospitalization rates are multifactorial, the quality of outpatient asthma management almost certainly plays a role. The NHLBI guidelines were published in 1991 and modified in 1997 in an attempt to streamline asthma management practices with an emphasis on increasing the awareness among physicians of the importance of appropriate classification of asthma severity to ensure adequate pharmacotherapy. Use of asthma action plans is encouraged to empower the primary caretaker to better manage exacerbations at home, with the aim of avoiding emergency department visits. There is also emphasis on the role of inflammation in the pathophysiology of asthma to encourage the use of inhaled steroids as the first line of management. While the role of antibiotics in acute asthma exacerbation was recently addressed in an update of the guidelines,13 the use of oral albuterol suspension and cough suppressants in the management of asthma is not as clearly defined in the guidelines and remains nebulous. Despite the availability of these guidelines for over a decade, outpatient management of asthma remains suboptimal.4 – 8 This situation may be a consequence of limited access to the guidelines for some PCPs. In their original form, the guidelines are a lengthy document requiring a significant amount of time to read, which is challenging for the time-pressed pediatrician.14 While hospital-based physicians are regularly exposed to updates on disease management practices in a concise manner through interactive CHEST / 129 / 3 / MARCH, 2006
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conferences such as grand rounds, it is more difficult for physicians in the community to be similarly exposed to concise updates. In our sample, it was noted that there was high adherence to the three positive practices selected from the guidelines in both groups. This result suggests strongly that knowledge about these practices has been widely disseminated in different forums among all the practicing providers. Recently the New York State Department of Health (NYSDOH) summarized the guidelines in a fourpage document that was mailed to all the practicing pediatricians in the NYSDOH registry. Also, as part of a Centers for Disease Control and Preventionfunded program at our hospital, the guidelines were obtained from National Institute of Health and distributed among the pediatricians practicing in the above three neighborhoods about 18 months prior to the administration of the questionnaire. The more significant finding of our study was the improper use of medications such as oral albuterol suspension and cough suppressants for wheezing episodes/acute exacerbations in asthmatic children. These two practices were employed extensively and significantly more often among the communitybased physicians as compared to the hospital-based physicians. While the use of cough suppressants has not been addressed clearly in the guidelines and has not been included in the summary document distributed by the NYSDOH, the American Academy of Pediatrics had issued a policy statement15 on the use of cough suppressants, noting that their efficacy was questionable. Accordingly, the policy statement emphasized that, in conditions such as asthma, cystic fibrosis, and bronchopulmonary dysplasia, where inflammation is the predominant underlying pathophysiologic component, cough suppression may adversely affect these patients by promoting pooling of secretions, secondary infections, and hypoxemia.15 While 37.5% of community-based physicians reported prescribing cough suppressants to asthmatic children sometimes or always, only 6.3% of hospital-based physicians reported the same practice. Similarly, the use of oral albuterol suspension has fallen out of favor over the past decade with the availability of better modalities of targeted inhaled drug delivery systems. These include the nebulizer solution and metered-dose inhalers with spacers. Oral albuterol preparations are not recommended for acute asthma exacerbations and have a limited place in chronic asthma management.16 In our study, 35.4% of community-based physicians reported prescribing albuterol sometimes or always, while only 6.2% of hospital-based providers reported prescribing it sometimes. While the practice of prescribing 622
albuterol syrup was infrequent among the hospitalaffiliated PCPs, it remains common among the community based PCPs, possibly due to their lack of more updated information. The third finding of preferential use of leukotrienes as first-line management for asthma in place of inhaled corticosteroids was a common practice among both groups of providers. This result was a surprising finding, as the guidelines clearly state the use of inhaled corticosteroids as the first line of therapy. This element of the guidelines has also been included in the summary document provided by the NYSDOH. While no further clarification was obtained in on this study, we hypothesize that this may be due to the practitioners’ perceptions of better compliance with preventive medications in the oral form as compared to the inhaled form. Maspero et al17 reported that practitioners believe that adherence is better for those medications administered via the oral route as compared to the inhaled route, and it affects their prescribing pattern. Whereas our findings reflect on the knowledge base regarding asthma management of PCPs in an inner-city environment, our study has certain limitations. It was conducted in a restricted geographic area, and findings may not be applicable to other urban settings. The questionnaire was exceptionally brief, so as to minimize refusal rates. Nonetheless, the six practices covered in the questionnaire were cardinal “do’s” and “don’ts” in the management of asthma. Hence, even though the questionnaire was brief, if the PCP did not respond with correct answers to these questions, it was less likely that he/she would be aware of the other finer details of the guidelines. As stated earlier, 132 pediatric PCPs were identified to be practicing in the South Bronx. Of these, 30% were hospital based while 70% were community based. While 80% of hospital-based PCPs were available, only 52% of the community-based PCPs were available when approached for the survey. The final limitation, therefore, concerns the possible bias introduced by the comparatively high unavailability rate. The idea that community-based practitioners less compliant with the NHLBI guidelines were systematically more compliant with our study invitation seems implausible but cannot be ruled out.
Conclusion This study investigated asthma management practices of health-care providers in different health-care settings to identify potentially harmful practices. Our results underscore the urgent need to increase awareness among community-based health-care proOriginal Research
viders about new developments and advances in the asthma field. However, since our study was geographically limited, further study of asthma management practices of pediatric primary care providers in other inner-city areas is required. To what extent suboptimal outpatient asthma management practices among PCPs contributes to the elevated pediatric asthma hospitalization rates in low-income neighborhoods warrants a separate investigation. While recommendations clearly stated in the guidelines and incorporated into summary documents have been followed by providers in varied clinical settings, potentially harmful practices remain common, as they have not been specifically addressed in the guidelines. While the need for greater incorporation of NHLBI guideline recommendations in outpatient asthma management has been highlighted in previous studies,4,5 our study is the first to evaluate the use of potentially harmful medications such as cough suppressants by PCPs caring for asthmatic children. This study highlights the need for an emphasis in the future guidelines not only on practices beneficial for better management of asthma but also on those that can potentially harm the patient or are of doubtful value. Publishing and disseminating summaries of the guidelines, emphasizing the positive practices as well as discouraging the potentially harmful practices, will likely increase better provider adherence to the guidelines. Providers in varied practice settings will have greater access in this summary document, leading to increased incorporation of the guideline recommendations in the outpatient management of asthmatics. This will lead to improved outpatient medical care and potentially decreased hospitalization rates among asthmatic children.
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References 1 Centers for Disease Control and Prevention. Asthma prevalence and control characteristics by race/ethnicity–United States, 2002. MMWR Morb Mortal Wkly Rep 2004; 53:145– 148 2 National Asthma Education and Prevention Program. Expert
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panel report: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institute of Health, 1991 National Heart, Lung, and Blood Institute. Expert panel report 2: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institute of Health, 1997 Warman KL, Silver EJ, McCourt MP, et al. How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? Pediatrics 1999; 103:422– 427 Scarfone RJ, Zorc JJ, Capraro GA. Patient self-management of acute asthma: adherence to national guidelines a decade later. Pediatrics 2001; 108:1332–1338 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 Doerschug KC, Peterson MW, Dayton CS, et al. Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med 1999; 159:1735–1741 Janson S, Weiss K. A national survey of asthma knowledge and practices among specialists and primary care physicians. J Asthma 2004; 41:343–348 Crim C. Clinical practice guidelines vs. actual clinical practice: the asthma paradigm. Chest 2000; 118:62S– 64S Asthma facts. 2nd ed. New York, NY: New York City Dept of Health and Mental Hygiene, 2000 Rabe K, Adachi M, Lai CKW, et al. Worldwide severity and control of asthma in children and adults: the Global Asthma Insights and Reality Surveys. J Allergy Clin Immunol 2004; 114:40 – 47 Aligne CA, Auinger P, Byrd RS, et al. Risk factors for pediatric asthma: contributions of poverty, race, and urban residence. Am J Respir Crit Care Med 2000; 162:873– 877 NAEPP expert panel report: guidelines for the diagnosis and management of asthma; update on selected topics 2002. Bethesda, MD: National Institutes of Health, 2002; Publication No. 02–5075 Barnes P. Asthma guidelines: recommendations versus reality. Respir Med 2004; (Suppl A):S1–S7 American Academy of Pediatrics. Committee on drugs: use of codeine- and dextromethorphan-containing cough remedies in children. Pediatrics 1997; 99:918 –920 Albuterol: drug summary information: MICROMEDEX Healthcare Series integrated index. Available at: www. micromedex/mdx1/mdxcgi/display.exe. Accessed March 14, 2005 Maspero JF, Duenas-Meza E, Volovitz B, et al. Oral montelukast versus inhaled beclomethasone in 6- to 11-year-old children with asthma: results of an open-label extension study evaluating long-term safety, satisfaction, and adherence with therapy. Curr Med Res Opin 2001; 17:96 –104
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