Practice Variation in Management of Childhood Asthma Is Associated with Outcome Differences

Abstract

Although specialist asthma care improves children's asthma outcomes, the impact of primary care management is unknown. To determine whether variation in preventive and acute care for asthma in pediatric practices affects patients' outcomes. For 22 practices, we aggregated 12-month patient data obtained by chart review and parent telephone interviews for 948 children, 3 to 12 years old, diagnosed with asthma to obtain practice-level measures of preventive (≥1 asthma maintenance visit/year) and acute (≥1 acute asthma visit/year) asthma care. Relationships between practice-level measures and individual asthma outcomes (symptom-free days, parental quality of life, emergency department [ED] visits, and hospitalizations) were explored using generalized estimating equations, adjusting for seasonality, specialist care, Medicaid insurance, single-family status, and race. For every 10% increase in the proportion of children in the practice receiving preventive care, symptom-free days per child increased by 7.6 days (P= .02) and ED visits per child decreased by 16.5% (P= .002), with no difference in parental quality of life or hospitalizations. Only the association between more preventive care and fewer ED visits persisted in adjusted analysis (12.2% reduction; P= .03). For every 10% increase in acute care provision, ED visits per child and hospitalizations per child decreased by 18.1% (P= .02) and 16.5% (P < .001), respectively, persisting in adjusted analyses (ED visits 8.6% reduction, P= .02; hospitalizations 13.9%, P= .03). Children cared for in practices providing more preventive and acute asthma care had improved outcomes, both impairment and risk. Persistence of improved risk outcomes in the adjusted analyses suggests that practice-level interventions to increase asthma care may reduce childhood asthma disparities.