Mayo Clinic Proceedings Home

Adherence to Asthma Guidelines in Children, Tweens, and Adults in Primary Care Settings

A Practice-Based Network Assessment



      To assess primary care adherence to 2007 US asthma guidelines.

      Patients and Methods

      Patients with persistent asthma aged 5 to 65 years from 22 primary care participating practices provided the data for this analysis of baseline information from the pragmatic randomized clinical trial the Asthma Tools Study. Using a combination of abstracted medical record data and patient-reported demographic information, we assessed the medical record documentation for elements of the 2007 US asthma guidelines. Elements assessed included documentation of (1) assessment of control, (2) factors that affect control (medication adherence evaluation, inhaler technique education, and evaluation for triggers), (3) self-management support (action plan), and (4) asthma medications prescribed (short-acting β-agonists and daily maintenance therapy). The baseline data was collected from March 16, 2009, to May 1, 2014.


      In 1176 patients (285 children, 211 tweens, and 680 adults) from 16 family medicine and 6 pediatric practices across the United States, documented guideline adherence was highest for prescription of medications (88.0% for short-acting β-agonists and 70.4% for maintenance medications) and lowest for an asthma action plan (3.1%). Documentation of control (15.0%) and factors that affect control (inhaler technique education, 7.6%; medication adherence assessment, 32.5%; and allergy evaluation, 32.5%) was not common and even less common for adults compared with children. A total of 22.2% of the enrolled patients had no asthma-related visit in the year before enrollment. Adherence to the nonmedication elements were higher in practices located in cities of more than 250,000 people and cities that used electronic medical records. Older patient age was negatively associated with guideline adherence.

      Conclusion and Relevance

      Adherence to asthma guidelines is poor in primary care practices, leaving many opportunities for improvement.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Simpson C.R.
        • Sheikh A.
        Trends in the epidemiology of asthma in England: a national study of 333,294 patients.
        J R Soc Med. 2010; 103: 98-106
        • Radhakrishnan D.K.
        • Dell S.D.
        • Guttmann A.
        • Shariff S.Z.
        • Liu K.
        • To T.
        Trends in the age of diagnosis of childhood asthma.
        J Allergy Clin Immunol. 2014; 134: 1057-1062.e5
        • Yawn B.P.
        • Wollan P.
        • Kurland M.
        • Scanlon P.
        A longitudinal study of the prevalence of asthma in a community population of school-age children.
        J Pediatr. 2002; 140: 576-581
      1. Centers for Disease Control and Prevention. Asthma: data, statistics and surveillance, 2013. Accessed February 8, 2016.

        • Kamble S.
        • Bharmal M.
        Incremental direct expenditure of treating asthma in the United States.
        J Asthma. 2009; 46: 73-80
        • Jang J.
        • Gary Chan K.C.
        • Huang H.
        • Sullivan S.D.
        Trends in cost and outcomes among adult and pediatric patients with asthma: 2000-2009.
        Ann Allergy Asthma Immunol. 2013; 111: 516-522
        • Moorman J.E.
        • Akinbami L.J.
        • Bailey C.M.
        • et al.
        National surveillance of asthma: United States, 2001-2010.
        Vital Health Stat 3. 2012; : 1-58
        • US Department of Health and Human Services
        Expert Panel Report III: Guidelines for the Diagnosis and Management of Asthma.
        US Dept of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Bethesda, MD2007 (NIH publication 07–4051)
        • Piecoro L.T.
        • Potoski M.
        • Talbert J.C.
        • Doherty D.E.
        Asthma prevalence, cost, and adherence with expert guidelines on the utilization of health care services and costs in a state Medicaid population.
        Health Serv Res. 2001; 36: 357-371
        • Senthilselvan A.
        • Lawson J.A.
        • Rennie D.C.
        • Dosman J.A.
        Regular use of corticosteroids and low use of short-acting beta2-agonists can reduce asthma hospitalization.
        Chest. 2005; 127: 1242-1251
        • Boulet L.P.
        Influence of obesity on the prevalence and clinical features of asthma.
        Clin Invest Med. 2008; 31: E386-E390
        • Wiener-Ogilvie S.
        • Pinnock H.
        • Huby G.
        • Sheikh A.
        • Partridge M.R.
        • Gillies J.
        Do practices comply with key recommendations of the British Asthma Guideline? if not, why not?.
        Prim Care Respir J. 2007; 16: 369-377
        • Lisspers K.
        • Ställberg B.
        • Hasselgren M.
        • Johansson G.
        • Svärdsudd K.
        Organisation of asthma care in primary health care in Mid-Sweden.
        Prim Care Respir J. 2005; 14: 147-153
        • Cabana M.D.
        • Slish K.K.
        • Nan B.
        • Lin X.
        • Clark N.M.
        Asking the correct questions to assess asthma symptoms.
        Clin Pediatr (Phila). 2005; 44: 319-325
        • Halterman J.S.
        • Kitzman H.
        • Mcmullen A.
        • et al.
        Quantifying preventive asthma care delivered at office visits: the Preventive Asthma Care-Composite Index (PAC-CI).
        J Asthma. 2006; 43: 559-564
        • Halterman J.S.
        • Auinger P.
        • Conn K.M.
        • Lynch K.
        • Yoos H.L.
        • Szilagyi P.G.
        Inadequate therapy and poor symptom control among children with asthma: findings from a multistate sample.
        Ambul Pediatr. 2007; 7: 153-159
        • Finkelstein J.A.
        • Lozano P.
        • Shulruff R.
        • et al.
        Self-reported physician practices for children with asthma: are national guidelines followed?.
        Pediatrics. 2000; 106: 886-896
        • Diette G.B.
        • Skinner E.A.
        • Markson L.E.
        • et al.
        Consistency of care with national guidelines for children with asthma in managed care.
        J Pediatr. 2001; 138: 59-64
        • Cabana M.D.
        • Ebel B.E.
        • Cooper-Patrick L.
        • Powe N.R.
        • Rubin H.R.
        • Rand C.S.
        Barriers pediatricians face when using asthma practice guidelines.
        Arch Pediatr Adolesc Med. 2000; 154: 685-693
        • Cabana M.D.
        • Rand C.S.
        • Becher O.J.
        • Rubin H.R.
        Reasons for pediatrician nonadherence to asthma guidelines.
        Arch Pediatr Adolesc Med. 2001; 155: 1057-1062
        • Wisnivesky J.P.
        • Lorenzo J.
        • Lyn-cook R.
        • et al.
        Barriers to adherence to asthma management guidelines among inner-city primary care providers.
        Ann Allergy Asthma Immunol. 2008; 101: 264-270
        • Mold J.W.
        • Fox C.
        • Wisniewski A.
        • et al.
        Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.
        Ann Fam Med. 2014; 12: 233-240
        • Yee A.B.
        • Fagnano M.
        • Halterman J.S.
        Preventive asthma care delivery in the primary care office: missed opportunities for children with persistent asthma symptoms.
        Acad Pediatr. 2013; 13: 98-104
        • Yawn B.P.
        • Bertram S.
        • Kurland M.
        • et al.
        Protocol for the asthma tools study: a pragmatic practice-based research network trial.
        Pragmatic Observ Res. 2013; 4: 7-18
        • Yawn B.P.
        • Brenneman S.K.
        • Allen-Ramey F.C.
        • Cabana M.D.
        • Markson L.E.
        Assessment of asthma severity and asthma control in children.
        Pediatrics. 2006; 118: 322-329
        • Beauchesne M.F.
        • Levert V.
        • El Tawil M.
        • Labrecque M.
        • Blais L.
        Action plans in asthma.
        Can Respir J. 2006; 13: 306-310
        • Bhogal S.
        • Zemek R.
        • Ducharme F.M.
        Written action plans for asthma in children.
        Cochrane Database Syst Rev. 2006; 3: CD005306
        • Baddar S.
        • Jayakrishnan B.
        • Al-Rawas O.A.
        Asthma control: importance of compliance and inhaler technique assessments.
        J Asthma. 2014; 51: 429-434
        • Yawn B.P.
        • Enright P.L.
        • Lemanske R.F.
        • et al.
        Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD.
        Chest. 2007; 132: 1162-1168
        • Yawn B.P.
        • Wollan P.
        Interrater reliability: completing the methods description in medical records review studies.
        Am J Epidemiol. 2005; 161: 974-977
        • Rank M.A.
        • Johnson R.
        • Branda M.
        • et al.
        Long-term outcomes after stepping down asthma controller medications: a claims-based, time-to-event analysis.
        Chest. 2015; 148: 630-639
        • Gionfriddo M.R.
        • Hagan J.B.
        • Hagan C.R.
        • Volcheck G.W.
        • Castaneda-Guarderas A.
        • Rank M.A.
        Stepping down inhaled corticosteroids from scheduled to as needed in stable asthma: systematic review and meta-analysis.
        Allergy Asthma Proc. 2015; 36: 262-267
        • Crans Yoon A.
        • Crawford W.
        • Sheikh J.
        • Nakahiro R.
        • Gong A.
        • Schatz M.
        The HEDIS medication management for people with asthma measure is not related to improved asthma outcomes.
        J Allergy Clin Immunol Pract. 2015; 3: 547-552
        • Cabana M.D.
        • Slish K.K.
        • Nan B.
        • Clark N.M.
        Limits of the HEDIS criteria in determining asthma severity for children.
        Pediatrics. 2004; 114: 1049-1055
        • Yawn B.P.
        • Wollan P.C.
        • Bertram S.L.
        • et al.
        Asthma treatment in a population-based cohort: putting step-up and step-down treatment changes in context.
        Mayo Clin Proc. 2007; 82: 414-421
        • Knapp J.F.
        • Simon S.D.
        • Sharma V.
        Does active dissemination of evidence result in faster knowledge transfer than passive diffusion? an analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009.
        Pediatr Emerg Care. 2015; 31: 190-196
        • Dombkowski K.J.
        • Cabana M.D.
        • Cohn L.M.
        • Gebremariam A.
        • Clark S.J.
        Geographic variation of asthma quality measures within and between health plans.
        Am J Manag Care. 2005; 11: 765-772
        • Podjasek J.C.
        • Rank M.A.
        Have expert guidelines made a difference in asthma outcomes?.
        Curr Opin Allergy Clin Immunol. 2013; 13: 237-243
        • Matui P.
        • Wyatt J.C.
        • Pinnock H.
        • Sheikh A.
        • Mclean S.
        Computer decision support systems for asthma: a systematic review.
        NPJ Prim Care Respir Med. 2014; 24: 14005
        • Shapiro A.
        • Gracy D.
        • Quinones W.
        • Applebaum J.
        • Sarmiento A.
        Putting guidelines into practice: improving documentation of pediatric asthma management using a decision-making tool.
        Arch Pediatr Adolesc Med. 2011; 165: 412-418
        • Wiener-Ogilvie S.
        • Huby G.
        • Pinnock H.
        • Gillies J.
        • Sheikh A.
        Practice organisational characteristics can impact on compliance with the BTS/SIGN asthma guideline: qualitative comparative case study in primary care.
        BMC Fam Pract. 2008; 9: 32
      2. National Institutes of Health, National Heart, Lung and Blood Institute. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma 1997. Accessed January 29, 2016.

      3. National Institutes of Health, National Heart, Lung, and Blood Institute, Expert Panel Report. Guidelines for the diagnosis and management of asthma–update on selected topics 2002. Accessed February 8, 2016.

      Linked Article

      • Correction
        Mayo Clinic ProceedingsVol. 91Issue 6
        • Preview
          In the Original Article entitled, “Adherence to Asthma Guidelines in Children, Tweens, and Adults in Primary Care Settings: A Practice-Based Network Assessment” published in the April 2016 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2016;91(4):411-421), the term electronic medical record should appear in Figure 1 instead of emergency medical record.
        • Full-Text
        • PDF