Adherence to Guidelines Varies in Treatment of Pediatric Asthma

Norra MacReady

March 15, 2010

March 15, 2010 (Anaheim, California) — Clinicians vary widely in their adherence to evidence-based guidelines for treating children with asthma, Angeline Ti reported in a poster session here at the American Medical Student Association 60th Annual Convention.

In some cases, following the guidelines had no impact on clinical outcomes, said Ms. Ti, a second-year student at the University of Michigan Medical School in Ann Arbor.

For her study, Ms. Ti reviewed the records of 200 randomly selected children, aged 2 to 18 years, admitted to the University of Michigan Hospital System for asthma exacerbations from January 1, 2007 to June 30, 2009.

To evaluate quality of care, each case was examined for inpatient use of systemic corticosteroids, short-acting beta-agonists (SABAs), and asthma action plans. All of these are listed as quality measures for pediatric asthma treatment by Hospital Compare, which Ms. Ti defined as "a national dataset provided by Medicare for patients to compare the quality of patient care across hospitals." She hypothesized that adherence to these measures would be associated with better outcomes, defined as fewer revisits and readmissions.

Virtually all of the children (99%) received a SABA at some time during their hospital stay, and nearly as many (92.5%) received a systemic corticosteroid. However, only 46% of the patients were discharged with a written asthma action plan. Furthermore, 36% of the patients revisited their asthma clinician or the emergency department within 1 year of hospitalization for an acute asthma exacerbation, and 16% of the patients required readmission.

"Failure to receive a SABA or oral corticosteroids was perfectly associated with not being readmitted to the hospital," Ms. Ti reported in her poster. Keeping follow-up appointments with the child's primary asthma care provider significantly reduced their chances of revisits or readmission, whereas admission to the pediatric pulmonary care unit or intensive care unit increased the risk for subsequent readmission.

In addition to showing a wide variation in adherence to the guidelines, these findings suggest that better outcomes do not necessarily result when the guidelines are observed, Ms. Ti said. "This could be less a problem with the guidelines and more a problem with having good measurable outcomes," she told Medscape Med Students. She also pointed out that, as a chronic illness, asthma is managed largely by patients and their families themselves, so that "many of the outcomes depend less on what the doctor does and more on the home environment and what the patient does."

It is also possible that the few children who did not receive steroids were less seriously ill, said Henry Milgrom, MD, professor of pediatrics at National Jewish Health in Denver, Colorado. "There is no question that patients with asthma who receive steroids do better than those who don't. Most doctors would give steroids during and after hospital admission, so the kids who did not get them may not have had asthma at discharge."

The guidelines do have their flaws, although they are always being improved, said Dr. Milgrom, who was not involved in this study. Currently, the guidelines are too long and too difficult to wade through during a busy clinical consultation. They do not include management of important cases, such as patients with allergies, and they do not pay enough attention to conditions that can mimic or coexist with asthma. "But overall, people with asthma need steroids. There's nothing else that's better."

"Initially, I was disappointed" at the spotty adherence to the guidelines, Ms. Ti admitted. Ultimately, however, she realized that many other variables are involved. "There's a lot more that goes into how well a child can control their asthma than whether or not they receive a certain medication."

American Medical Student Association (AMSA) 60th Annual Convention: Abstract 25. Presented March 11, 2010.

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