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Time for a New Paradigm for Asthma Management

      The study by Yawn et al
      • Yawn B.P.
      • Rank M.A.
      • Cabana M.D.
      • et al.
      Adherence to asthma guidelines in children, tweens, and adults in primary care settings: a practice-based network assessment.
      in this issue of Mayo Clinic Proceedings examined adherence by primary care physicians to practice guidelines published by the National Asthma Education and Prevention Program (NAEPP). That program, developed within the National Heart, Lung, and Blood Institute of the National Institutes of Health, was an attempt to address the high level of morbidity from asthma. A Coordinating Committee of the NAEPP convened an Expert Panel, and the first publication of guidelines from that Expert Panel was in 1991.
      National Asthma Education Program
      Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma.
      Subsequent Expert Panel Reports provided updates of asthma guidelines in 1997, 2002, and 2007.
      National Asthma Education Program
      Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma.
      National Asthma Education Program
      Updates on Selected Topics from Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma.
      National Asthma Education Program
      Expert Panel Report 3: Summary Report Guidelines for the Diagnosis and Management of Asthma.
      Despite efforts to disseminate the NAEPP guidelines and encourage their application in routine care, asthma has continued to be the leading cause of hospital admission for children in the United States. More than 5% of all pediatric hospital admissions have a primary diagnosis of asthma based on two national databases: the Kids Inpatient Database (n=2,684,000) and the Pediatric Health Information System (n=512,945).
      • Keren R.
      • Shah S.S.
      JAMA pediatrics hospital medicine theme issue.
      There is also concern that the actual prevalence of hospitalized asthma may be higher than reported because of frequent missed diagnoses and underdiagnoses. Pneumonia, which also accounts for approximately 5% of pediatric hospital admissions,
      • Keren R.
      • Shah S.S.
      JAMA pediatrics hospital medicine theme issue.
      may include children who have symptoms consistent with viral respiratory infection–induced asthma.
      • Gowraiah V.
      • Awasthi S.
      • Kapoor R.
      • et al.
      Can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? a prospective observational study in four Indian hospitals.
      Symptoms of asthma have also been identified as bronchitis.
      • Joseph C.L.
      • Foxman B.
      • Leickly F.E.
      • Peterson E.
      • Ownby D.
      Prevalence of possible undiagnosed asthma and associated morbidity among urban schoolchildren.
      Asthma is, therefore, a major cause of morbidity in children, and it has shown few signs of abating.
      • Akinbami L.J.
      • Simon A.E.
      • Rossen L.M.
      Changing trends in asthma prevalence among children.
      These concerning statistics persist despite the very detailed guidelines that purport to provide methods to improve asthma outcome. In fact, this is the conundrum: An Expert Panel repeatedly publishes guidelines designed to provide improvement in outcome, but when the process is examined, there is little change in the outcome during the many years of published guidelines.
      • Weinberger M.
      Seventeen years of asthma guidelines: why hasn't the outcome improved for children?.
      The report by Yawn et al
      • Yawn B.P.
      • Rank M.A.
      • Cabana M.D.
      • et al.
      Adherence to asthma guidelines in children, tweens, and adults in primary care settings: a practice-based network assessment.
      indicates that the guidelines were not followed, implying that following the guidelines would improve outcome. But is that a realistic expectation? An example of a well-intentioned but futile application of a specific component of the guidelines was reported by the Joint Commission on Accreditation of Hospitals during examination of quality measures at children's hospitals. They found “moderate compliance” with provision of a home management plan at hospital discharge but no association between the provision of that plan and either subsequent asthma-related emergency care or hospitalization.
      • Morse R.B.
      • Hall M.
      • Fieldston E.S.
      • et al.
      Hospital-level compliance with asthma care quality measures at children's hospitals and subsequent asthma-related outcomes.
      Sheares et al
      • Sheares B.J.
      • Mellins R.B.
      • Dimango E.
      • et al.
      Do patients of subspecialist physicians benefit from written asthma action plans?.
      similarly reported no benefit from written action plans, but as indicated in a recent letter to the editor, “the devil's in the details.”
      • Weinberger M.
      Written asthma action plans: the devil's in the details.
      Simply following a guideline, no matter how well-intentioned, does not ensure a successful outcome for a complex and variable problem such as asthma, and it is outcome that is the relevant measure, not just the process.
      But care of asthma in some clinical settings, even some preceding the asthma guidelines, has been associated with outcomes to which the guidelines aspire but have not attained. In 1988, 3 years preceding the first NAEPP report, Bucknall et al
      • Bucknall C.E.
      • Robertson C.
      • Moran F.
      • Stevenson R.D.
      Differences in hospital asthma management.
      substantiated differences in outcome for adult patients admitted to different clinical services of a United Kingdom Health Service Hospital. Sixty-four patients were admitted on a rotational basis to a service where there was a physician with special interest in respiratory medicine, and 86 were admitted to a clinical service without a physician with this interest.
      • Bucknall C.E.
      • Robertson C.
      • Moran F.
      • Stevenson R.D.
      Differences in hospital asthma management.
      Tenfold fewer readmissions, 2% vs 20%, occurred the following year among those initially admitted to the clinical service where there was a physician with special interest in respiratory medicine. In 1990, a year before the first publication of the NAEPP guidelines, Mayo et al
      • Mayo P.H.
      • Richman J.
      • Harris H.W.
      Results of a program to reduce admissions for adult asthma.
      described the outcome of 104 inner-city adult patients hospitalized with acute asthma at Bellevue Hospital Center in New York, New York. Subsequent to discharge, 47 patients were randomly assigned to an intensive outpatient treatment clinic where a pulmonologist with special interest in asthma and a nurse practitioner provided care, and 57 continued to receive their previous outpatient care. The intensive treatment program was associated with 3-fold fewer readmissions than the continued use of previous outpatient care in the general pulmonary clinic at the same hospital.
      Outcome in children has also been substantially improved by programs providing comprehensive care for asthma by experienced and knowledgeable subspecialty personnel. This was demonstrated in a controlled trial of 80 children, aged 2 to 16 years, receiving Medicaid in Norfolk, Virginia, who were randomly assigned to remain in the general pediatric clinic or to the allergy clinic at the Children's Hospital of the King's Daughters.
      • Kelly C.S.
      • Morrow A.L.
      • Shults J.
      • Nakas N.
      • Strope G.
      • Adelman R.D.
      Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in Medicaid.
      That study demonstrated a 3-fold decrease in hospitalizations and a 2-fold decrease in emergency care visits when patients assigned to the allergy clinic were compared with those who remained in the general clinics at the same institution. Great improvement in asthma outcome also has been described for a program in an inner-city pediatric population. This was accomplished by providing subspecialty-based asthma care in mobile asthma clinics designed to reduce barriers to delivering effective asthma care.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      Comparing pre- and post-year data, a 66% reduction in emergency department visits, an 84% reduction in hospitalizations, and a substantial reduction in days of missed school were described.
      What is different about programs that focus on asthma care? Asthma is a complex chronic disease with variable clinical presentations and often unpredictable fluctuations in symptoms. Compared with usual ambulatory care, such programs are likely to involve subspecialists with more training, knowledge, and experience regarding asthma. Programs focusing on asthma care are more likely to monitor the clinical course rather than seeing the patient only when symptomatic. Measurements of airway function are likely to be used for capable patients. Personnel in such programs are more likely to be familiar with the various medication options and devices used for aerosol delivery. Personnel in such programs are also more likely to demonstrate the use of specific aerosol delivery devices and ensure that the patient can successfully use and receive the aerosol medication. At an asthma care program, medication instruction is likely to be tailored to the individual based on an assessment from a subspecialty clinician with experience and knowledge of asthma, supported by experienced nonphysician health care providers and educators.
      Consideration of how care in such programs differs from other usual ambulatory care explains why the prodigious efforts by the NAEPP Expert Panels are not effective. If we are to optimally improve the outcome of this complex disease we call asthma, particularly for patients with more severe disease, input is needed from health care providers who possess expertise and considerable experience. Subspecialists acquire that expertise in their training and maintain their skills through continued exposure to the various manifestations of asthma. Yawn et al
      • Yawn B.P.
      • Rank M.A.
      • Cabana M.D.
      • et al.
      Adherence to asthma guidelines in children, tweens, and adults in primary care settings: a practice-based network assessment.
      close their article by indicating that their “data suggest extensive opportunities for improvement in implementing asthma guidelines within primary care practices in the United States.” Because the NAEPP guidelines have now been available for 24 years, it seems naive to suggest that widespread implementation of those asthma guidelines will occur, and it may be little more than wishful thinking that asthma outcome will then substantially improve. A different paradigm is needed in which problematic asthma is cared for in programs that are served by subspecialty-trained, experienced health care personnel.
      An often-stated cliché is the definition of insanity: doing the same thing over and over again and expecting different results. The various phenotypes of pediatric asthma are generally highly responsive to appropriate management by knowledgeable and experienced health care personnel who have the time and ancillary resources needed to provide optimal care. The current status of the high rate of emergency care and hospitalization at major children's hospitals in the United States is a function of ineffective health care delivery, not an inherent lack of data or effective therapy. The care is ineffective because it is generally provided by physicians who are primarily involved with acute symptoms in the emergency department or hospital. There is a missed opportunity to enter a patient with asthma in the acute setting into an asthma care program before or at the time of the acute care.
      Although focused asthma care programs should be available at all children's hospitals and other community settings where facilities and personnel are available, enrollment in such asthma care programs may not be available in rural and other practice venues far removed geographically and logistically from the aforementioned resources. Solutions for these practice niches for asthma have been investigated using telemedicine.
      • Brown W.
      • Odenthal D.
      The uses of telemedicine to improve asthma control.
      • Portnoy J.
      • Waller M.
      • Dinaker C.
      TeleAllergy: a new way to manage asthma.
      Although these initial reports are small, the use of telemedicine to provide input from successful asthma care programs to areas far from such centers shows sufficient promise to warrant further investigation.
      We are long overdue to recognize that guidelines, no matter how detailed and how extensively disseminated, cannot substitute for clinical care delivered by the most highly trained and most experienced physicians, with their efforts augmented by equally experienced nonphysician health care providers, laboratory facilities, and patient education programs. The need for programs focused on care for adults and children with asthma who require urgent care and hospitalization has recently been recognized in the United Kingdom.
      • Kane B.
      • Cramb S.
      • Hudson V.
      • Fleming L.
      • Murray C.
      • Blakey J.D.
      Specialised commissioning for severe asthma: oxymoron or opportunity?.
      The published evidence and experience support the development of similar programs in the United States if the national asthma outcome statistics are to be improved.

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        Adherence to asthma guidelines in children, tweens, and adults in primary care settings: a practice-based network assessment.
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