Use of Asthma Guidelines by Primary Care Providers to Reduce Hospitalizations and Emergency Department Visits in Poor, Minority, Urban Children

Abstract

Purpose of the Study. To determine if a standardized citywide asthma management program delivered by primary care providers (PCPs) would increase adherence with the National Asthma Education and Prevention Program guidelines and whether this would improve medical service utilization. Study Population. Children between 6 months and 18 years of age (n = 8324) who presented for care at any of 6 primary care clinics in Hartford, Connecticut, between 1998 and 2002 and had enrolled in either Medicaid or the State Children’s Health Insurance Plan (SCHIP). Methods. Enrollment in the Easy Breathing asthma management program for PCPs included completing a survey regarding the child’s clinical history, provider assessment of asthma severity, and a written asthma treatment plan for the caregiver. Providers underwent training in the Easy Breathing curriculum. Data regarding demographics for enrolled patients were obtained from the survey and compared with all resident children in Hartford. Claims data were obtained. Utilization of medical services and prescriptions was examined. Children were continuously enrolled in the program during the 4-year analysis period. Relative rates of utilization (in event/child-months) were compared for the same children before and after enrollment. Results. Of the 1799 children with persistent asthma, only 38% were treated with antiinflammatory therapy before Easy Breathing; after enrollment, this improved to 96%, with 85% of those treated specifically with an inhaled corticosteroid. After enrollment in Easy Breathing, the rate of hospitalization for all children with asthma decreased 35% (P < .006), and the decrease was sustained over 3 years. There was a 27% overall decrease in emergency department (ED) visits for asthma (P < .01) and less seasonal variation in hospitalizations. Adjusted relative rates for total and asthma-specific ED and hospital visits decreased significantly for children with persistent asthma. Decreases in adjusted rates of outpatient visits after enrollment were also found for children overall (19%; P < .0001). This was true for children with intermittent asthma (22%; P < .001) and persistent asthma (18%; P < .001). Conclusions. Adherence to National Asthma Education and Prevention Program guidelines by PCPs managing asthma for low-income minority children decreased their total number of hospitalizations and asthma-specific ED visits and outpatient visits. The authors believe that contributors to the success of the program include the standardized approach to therapy, including inhaled corticosteroids when indicated, as well as the development of a written, individualized asthma treatment plan. The benefits of the program continued through the 3 years. Reviewer Comments. Despite a few limitations (nonrandomized, use of claims data), this study strongly reinforces the idea that improving asthma management relies not only on patient adherence but also physician review and faithful implementation of the current guidelines. PCPs managing asthma in low-income, urban, minority children would benefit the community by participating in such standardized programs that are focused on diagnosis and treatment. This not only decreases the morbidity related to asthma in these children but also alleviates the financial burden involved in excessive utilization of medical services.