Controller Medication Use Research Articles

Emergency Department Allies: A Controlled Trial of Two Emergency Department–Based Follow-up Interventions to Improve Asthma Outcomes in Children

We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation. Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program. The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use. Three hundred fifty-two children were enrolled; 78% completed follow-up, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups. ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period.

Particulate Levels Are Associated with Early Asthma Worsening in Children with Persistent Disease

Ambient particulate concentrations have been associated with variable physiologic effects in children with persistent asthma taking controller medications. To determine whether exposure to particulate matter has immediate effects on asthma control in children with persistent disease. In a school-based cohort, 73 children, primarily with moderate and severe asthma, were followed daily over one or two winters (2001-2002, 2002-2003) in Denver, Colorado. The association among ambient fine particulate, bronchodilator use, and urinary leukotriene E4 levels was assessed. Daily concentrations of fine particulate peaked in the morning hours when children were commuting to school. In a multivariable analysis that controlled for meteorology, time trends, and upper respiratory infections, an increase of one interquartile range in morning maximum fine particulate levels was related to an average increase of 3.8% in bronchodilator usage at school (95% confidence interval [CI], 0.2-7.4; p = 0.04). Children with severe asthma demonstrated significantly stronger associations (8.1% increase; 95% CI, 2.9-13.4; p = 0.003) than those with mild/moderate disease (1.6% increase; 95% CI, -2.2-5.4; p = 0.41; p = 0.03 for difference between groups). Morning maximum fine particulate levels were also associated with urinary leukotriene E4 measured during school hours (average increase of 6.2% per interquartile range increase; 95% CI, 1.9-10.5; p = 0.006). These associations were not discernable when 24-h averaged concentrations were used. Peak concentrations of ambient fine particulate are associated with early increases in bronchodilator use and urinary leukotriene E4 levels among children with persistent asthma, despite the use of controller medications.

Asthma Medication Health Beliefs and Controller Medication Use in Inner City Children

Asthma Medication Health Beliefs and Controller Medication Use in Inner City Children

Asthma Severity Predicts Future Asthma Morbidity in Inner-City Preschool Children but Controller Medication Use is Not an Important Additional Predictor

Asthma Severity Predicts Future Asthma Morbidity in Inner-City Preschool Children but Controller Medication Use is Not an Important Additional Predictor

Asthma Medication Use in School-Aged Children

Using data from the1996, 1998, and 2000 Medical Expenditure Panel Survey, this study assessed controller medication use in a national representative sample of school-aged children with persistent asthma. Children 5 to 17 years of age with persistent asthma were identified in accordance with the Health Employer Data and Information Set specifications. Nonuse of controllers and excess use of relievers were common. In addition, controller medications were significantly less likely to be purchased for younger children, black and Hispanic children, and white children whose mothers had at least a college education. Efforts to improve childhood asthma management are needed, especially for those children.

Health Effects of Ultraviolet Irradiation in Asthmatic Children's Homes

Objective. Centrally installed ultraviolet (UV) irradiation units were investigated to determine the potential health benefits in mold-sensitized asthmatic children. Methods. Nineteen mold-sensitized asthmatic children 5 to 17 years of age with home central ventilation systems were enrolled in a 28-week double-blinded placebo controlled cross-over trial. Clinical outcome measurements included morning and evening peak expiratory flow rates (PEFR), PEFR variability, change in forced expiratory volume in 1 second (FEV1), change in total rhinoconjunctivitis and asthma symptom scores, change in rhinoconjunctivitis and asthma quality-of-life scores, and total (rescue and controller) medication use from baseline and between time periods. Environmental outcomes included changes in temperature, relative humidity, dew point, and indoor airborne mold and bacterial counts from baseline and between time periods. Analysis of variance (ANOVA) and regression analysis and t test were used to evaluate relationships between environmental exposure(s) and clinical outcome measurements during each study period. Results. Twelve male and seven female children, average age 10.6 years, were enrolled. A statistically significant improvement in PEFR variability in subjects receiving CREON2000 units followed by placebo units was observed (p < 0.05) across both treatment periods. Within group analysis during treatment period 1, a statistically significant improvement in reduction of asthma symptom scores, the number of days with asthma symptoms, total asthma medication use, and PEFR variability were observed in subjects receiving CREON2000 units versus placebo units (p < 0.05). No significant differences were observed between the CREON 2000 and placebo units for other clinical or environmental outcome measurements. Conclusions. Central UV irradiation was effective at reducing airway hyperresponsiveness manifested as PEFR variability and some clinical symptoms. A larger cohort controlled longitudinal study to validate the clinical health effects of UV irradiation as a primary indoor environmental intervention for allergic asthma is necessary to confirm this finding.

Association of Atopy to Asthma Severity and Medication Use in Children

The importance of aeroallergens as triggers for asthma is well recognized, but the relationship between asthma severity and atopic profiles in childhood has not been elucidated. This study assessed the relationship of allergen sensitization to asthma severity in a study of 114 asthmatic children followed for 8 weeks in three Southern California areas. Increased controller medication and β-agonist use were positively associated with number of positive skin tests and allergy to mold and pollens. Mold was associated with increased asthma symptoms. Degree of atopy and reactivity to mold and pollens plays a significant role in asthma severity in asthmatic children.

Exposure to Tobacco Smoke and Chronic Asthma Symptoms

The objective was to determine if tobacco exposure is associated with year-round asthma symptoms. We analyzed baseline data from a multistate survey of 896 pediatric patients with asthma participating in a randomized controlled trial. Daytime symptoms, nocturnal symptoms, and limitations in activity because of asthma tend to increase during the winter season (p < 0.05 for all comparisons, except spring to winter daytime symptoms). One hundred forty of 896 (16%) children had year-round symptoms (i.e., active asthma symptoms during every season). Using separate multivariate analyses, we found that having a parent who smokes (odds ratio [OR]: 2.22; 95% confidence interval [CI]: 1.35, 3.64) or a member of the household who smokes (OR: 1.94; 95% CI: 1.29, 2.93) was associated with a higher likelihood of year-round symptoms, controlling for region of residence, insurance status, and use of a daily controller medication. Asthma symptoms are more likely to increase in the winter season. In anticipation of these p...

RSD1235 in the Treatment of Recent Onset Atrial Fibrillation in ACT I, (Atrial Arrhythmia Conversion Trial I) - Effect of Age, Sex, and Prior Rate Control Medications

Objectives: To assess the effect of age, sex, and the use of rate control medications on the conversion of atrial fibrillation (AF) to sinus rhythm (SR) using a novel drug RSD1235.

Asthma morbidity and treatment in the Chicago metropolitan area: one decade after national guidelines

A number of studies have demonstrated disproportionate hospitalization and mortality rates in US urban areas. Yet, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. To examine asthma morbidity and medical care in a population-based sample of adults and children with asthma residing in the greater Chicago, IL, metropolitan area and to explore social and demographic influences on morbidity and treatment. A telephone survey of adults living in the Chicago metropolitan area was conducted from November 1999 through December 2000. The final sample included 152 adults and children with active asthma. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Of current medication users, 32.2% reported current regular use of controller medications. After adjusting for age, sex, income, education, and reported current pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area and that a large gap remains between the goals of asthma therapy and appropriate treatment as defined by the National Asthma Education and Prevention Program. The reasons for disparate treatment and health outcomes by race/ethnicity and income need further study and intervention.

Comparing Responses: Leukotrienes Versus Inhaled Corticosteroids

Source: Szefler SJ, Phillips BR, Martinez FD, et al for the Childhood Asthma Research and Education Network of the National Heart, Lung, and Blood Institute. Characterization of within-subject responses to fluticasone and montelukast in childhood asthma. J Allergy Clin Immunol. 2005;115:233–242.Currently, 2 classes of controller medications are commonly used in children with persistent asthma: inhaled corticosteroids (ICS) and leukotriene receptor antagonists (LTRA). Little work has been done to characterize the phenotypic features of children with asthma that respond to both, one, or neither of the medication classes. To address this question, the National Heart, Lung, and Blood Institute (NHLBI) funded a Childhood Asthma Research and Education (CARE) Network multi-center, double-masked trial. In this investigation, 144 children ages 6 to 17 years with mild to moderate persistent asthma were randomized to 1 of 2 crossover sequences. Both sequences included 8 weeks of an active ICS (fluticasone 100 mcg BID) plus an oral placebo, and 8 weeks of an inhaled placebo plus age-appropriate doses of an LTRA (montelukast, 5 mg for those ages 6 to 14 years and 10 mg for 15- to 18-year-old children). Because the study utilized a crossover design, it allowed for within-subject characterization of children that responded to both, neither, or only one of the study drugs.In the 126 patients that successfully completed this investigation, the mean improvement in forced expiratory volume in 1 second (FEV1) was 6.8% for fluticasone and 1.9% for montelukast. Importantly, a response to a medication was defined as an improvement in FEV1 of 7.5%. Seventeen percent of participants achieved this threshold with both medications, while 23% responded to fluticasone only and 5% responded to montelukast only. Fifty-five percent responded to neither.In characterizing those that responded better to one drug over the other, the investigators reported that patients with higher baseline levels of exhaled nitric oxide (eNO), total eosinophil count, eosinophilic cationic protein, and IgE, and lower baseline levels on pulmonary function testing responded better to fluticasone compared to those who responded to neither medication. Subjects responding to montelukast were younger and had a shorter duration of asthma than those responding to neither drug. Finally, the subjects who responded to both medications had higher levels of urinary leukotrienes and poorer baseline lung function on pulmonary function testing than those who responded to neither drug. One other notable finding was that while only 2 children developed acute asthma exacerbations that required oral steroids while receiving active fluticasone plus oral placebo, 10 required oral steroids while receiving montelukast and no active ICS.The investigators concluded that while a large portion of the children with persistent asthma had similar responses to both medications, children with low pulmonary function or markers indicative of allergic inflammation are more likely to respond to ICS. Alternatively, those without such features may benefit from a trial of either class of medication.Dr. Paul is a co-investigator with the Data Coordinating Center (DCC) for the Childhood Asthma Research and Education (CARE) Network, but he is not a co-author on this study. Dr. Paul has not disclosed any financial relationships relevant to this commentary.The National Asthma Education and Prevention Program’s Guidelines for the Diagnosis and Management of Asthma published by the NHBLI give evidence-based guidance on the use of controller medications for the treatment of persistent asthma.1,2 Future versions of these guidelines will likely reflect the future of therapeutics, which will shift from population-based to individual-based treatment. Individualized therapy will rely on investigations like the one summarized above to incorporate a patient’s disease phenotype and genotype into medical decision-making. While many of the tests used to characterize the asthma phenotypes described in this asthma study are not yet widely available or accessible to clinicians, they may be in the near future.In this study, the advantage goes to ICS over LTRA, but that is based on one FEV1 measurement at the end of an 8-week trial of one of these medications. The reliability of a single test of pulmonary function as an outcome measure is questionable. In addition, the authors did not assess whether there was a synergistic effect of the full monte: that is, combined therapy with a LTRA such as montelukast and inhaled steroid.

Application of Quality-Improvement Methods in a Community Practice: The Sandhills Pediatrics Asthma Initiative

This case study demonstrates the use of quality improvement methods to improve asthma care in a busy community practice. The practice used disease-management strategies, such as population identification, self-management education, and performance measurement and feedback. The practice then applied several practice-based quality improvement methods, such as PDSA cycles, to improve care. From 1998 to 2003, process measures, such as staging of asthmatics, use of long-term control medications, use of peak flow meters and spacers, and use of action plans, improved. There was also a substantial decrease in emergency department use and hospitalizations among patients with asthma. Although there have been several studies demonstrating the efficacy of disease management strategies, most lack generalizability to community practices. Often, interventions are so intensive and cumbersome, that they are unlikely to be replicated in primary care setting. Researchers have been unable to determine which components of the interventions are most effective and replicable. Furthermore, many studies of disease management strategies enroll participants who lack the co-morbidities seen in community practice. There are also few studies of disadvantaged populations that face other barriers to care, such as lack of transportation, poor access to specialists, and medical illiteracy. In this case study, there were several unique factors that enabled the practice to improve care for this population. The AccessCare case manager who worked with the practice not only provided data and feedback to the practice team, but also served as an improvement "coach," often pushing the team and facilitating many of the improvement efforts. AccessCare's approach is in contrast to many of the commercial disease management companies' "carve out" models that do not sufficiently involve providers or practices in their interventions. The other necessary ingredient for success in this project was organizational leadership and support. The leaders of the practice saw beyond the usual metrics of patient visit counts and relative value units (RVUs) to embrace the concept of population health: the notion that practices are not only responsible for providing acute, episodic care in the office, but also for improving health outcomes in the community in which they serve. Other important factors included ensuring a basic agreement among providers on the need for improvement and frequent communication about the goals of the project. Although the champions of the project tried to minimize formal meeting time, there was frequent informal communication between team members. In the future, there is a need to develop other approaches to stimulate these endeavors in community practices, such as "pay for performance" programs, continuing education credit, and tying maintenance of board certification to quality improvement initiatives.

The Management of Asthma and Rhinitis during Pregnancy

Asthma and rhinitis frequently complicate pregnancy. The course of asthma may be adversely altered by gestation, placing the mother and fetus at risk. Therefore, pregnant patients with persistent asthma require an aggressive asthma management plan that includes environmental control measures and the use of long-term controller medications. Inhaled corticosteroids (ICSs) are the preferred long-term controller medication for persistent asthma, based on efficacy. However, safety concerns regarding corticosteroids may cause physicians or patients to seek an alternate, less effective treatment during pregnancy. The Food and Drug Administration's pregnancy category ratings are based on animal and human safety data. Because ICSs were previously rated pregnancy category C (i.e., with human studies lacking and animal studies either lacking or positive for fetal risk), other asthma controllers, such as cromolyn and nedocromil, that carry a pregnancy category B rating (i.e., showing no evidence of fetal risk in humans or animal studies negative for fetal risk) appeared to be more desirable for use during pregnancy. One ICS, budesonide, was reclassified as pregnancy category B based on human data supporting its use during pregnancy. In moderate and severe persistent asthma, add-on therapy may be considered, including long-acting beta2-adrenergic agonists, leukotriene receptor antagonists, and theophylline. Because rhinitis may adversely affect quality of life and the course of asthma, recommendations for aggressive management also apply.

Underuse of Controller Medications Among Children With Persistent Asthma in the Ohio Medicaid Population: Evolving Differences With New Medications

Despite innovations in asthma care, morbidity and mortality have increased significantly. Underuse of controller medications is a major contributor to increased morbidity and mortality. To determine the extent of underuse of asthma controller medications among Ohio Medicaid children and to determine if there are racial differences in controller medication claims. We conducted a retrospective analysis of Ohio Medicaid claims data. The source data included all institutional, medical service, and pharmacy claims for fee-for-service patients between January 1, 1997, and December 31, 2001. We identified children with persistent asthma using Health Employer Data Information System criteria. The primary outcome was a controller medication claim. We used multivariable logistic regression to identify risk factors for underutilizing asthma controller medications and applied generalized estimating equations to account for repeated measures. The proportion of children with claims for a controller medication increased from 53% in 1997 to 67% in 2001. Although there were no racial differences in medication claims in 1997, a smaller proportion of African American children had a claim for a controller medication in 2001 (64.8% vs 67.8%, P < .001). Leukotriene antagonists (LTAs) were driving this difference. Individuals residing in urban areas were significantly less likely to have claims for LTAs when compared with those who resided in nonurban areas. Overall use of asthma controller medications among Ohio Medicaid children was poor. There was a widening racial difference in controller medication claims over the 5-year study. Regional differences in LTA claims were driving this racial difference.

Compliance with NAEPP asthma guidelines in a hospital based pediatric clinic and school based health clinics after an asthma education program

RATIONALE: Implementation of NAEPP Asthma Guidelines is not fully embraced by primary-care practitioners. To improve compliance, a hospital based pediatric clinic(HBPC) and school based health clinics(SBHC) located in inner city Brooklyn participated in an asthma education program which trained the primary-care practitioners in the guidelines. During the program, compliance was excellent evidenced by classification of asthma severity 83%(179/216) of visits. Documentation of asthma action plans and appropriate use of controller medication was greater than 90%(101/110). This study evaluates compliance one year after cessation of the intensive asthma education program.METHODS: Charts from the initial study were reviewed. Compliance was measured by tracking the documentation of asthma severity, asthma action plans, and appropriate use of controller medication during visits that occurred after program cessation.RESULTS: 820 visits were reviewed. The SBHC classified asthma severity in 66%(310/469), appropriately used controller medication in 72%(39/54) and reviewed asthma action plans in 41%(194/469) of visits. The HBPC classified asthma severity in 55%(192/351), appropriately used controller medication in 74%(51/69) and reviewed asthma action plans in 28%(97/351) of visits.CONCLUSIONS: The initial asthma education program improved primary-care practitioners' compliance with asthma guidelines. After cessation of program, compliance decreased in both clinic settings, however more so in the HBPC. Continuity may be a factor as the HBPC is staffed by multiple residents and attending physicians whereas the SBHC is staffed by fulltime nurse practitioners. However, even when continuity existed with the HBPC attending physicians, compliance remained poor. Possibly more frequent guideline training will convince physicians to utilize the NAEPP asthma guidelines. RATIONALE: Implementation of NAEPP Asthma Guidelines is not fully embraced by primary-care practitioners. To improve compliance, a hospital based pediatric clinic(HBPC) and school based health clinics(SBHC) located in inner city Brooklyn participated in an asthma education program which trained the primary-care practitioners in the guidelines. During the program, compliance was excellent evidenced by classification of asthma severity 83%(179/216) of visits. Documentation of asthma action plans and appropriate use of controller medication was greater than 90%(101/110). This study evaluates compliance one year after cessation of the intensive asthma education program. METHODS: Charts from the initial study were reviewed. Compliance was measured by tracking the documentation of asthma severity, asthma action plans, and appropriate use of controller medication during visits that occurred after program cessation. RESULTS: 820 visits were reviewed. The SBHC classified asthma severity in 66%(310/469), appropriately used controller medication in 72%(39/54) and reviewed asthma action plans in 41%(194/469) of visits. The HBPC classified asthma severity in 55%(192/351), appropriately used controller medication in 74%(51/69) and reviewed asthma action plans in 28%(97/351) of visits. CONCLUSIONS: The initial asthma education program improved primary-care practitioners' compliance with asthma guidelines. After cessation of program, compliance decreased in both clinic settings, however more so in the HBPC. Continuity may be a factor as the HBPC is staffed by multiple residents and attending physicians whereas the SBHC is staffed by fulltime nurse practitioners. However, even when continuity existed with the HBPC attending physicians, compliance remained poor. Possibly more frequent guideline training will convince physicians to utilize the NAEPP asthma guidelines.

Reduced activation by systemic glucocorticoid of the AP-1 component c-jun in bronchial mucosal cells of GC sensitive, but not resistant asthmatics

Component c-jun in Bronchial Mucosal Cells of GC Sensitive, but Not Resistant Asthmatics C. J. Corrigan, K. Mallett, T. Loke, J. Ratoff, B. O’Connor, T. Lee; Asthma, Allergy & Respiratory Science, Guy’s. King’s and St. Thomas’ School of Medicine, London, UNITED KINGDOM. RATIONALE: Our previous studies implicate the transcriptional regulatory factor AP-1, composed of c-fos and c-jun, in the regulation of the clinical response of asthmatics to systemic GC therapy. We hypothesised that c-fos expression and c-jun phosphorylation are increased in the bronchial mucosa of GC resistant, as compared with sensitive asthmatics and differentially regulated by systemic GC. METHODS: We used immunohistochemistry with validated antibodies and digital image analysis to measure the expression of c-fos and total and phosphorylated c-jun (c-junP) in mucosal inflammatory cells in endobronchial biopsies from 9 GC sensitive (∆FEV1>25%, age 35-67 yr) and 20 GC resistant (∆FEV1 3 visits were analyzed at baseline and after 3 visits for asthma severity, medication use, urgent care visits, and missed school days. RESULTS: From 3/01-1/04, 440 children were evaluated with a mean age of 8 yrs (range 3-18), 46.4% female, 91.6% African American, >60% Medicaid and 70% with persistent asthma. At baseline, 20.9% were on albuterol alone and 9.8% on no medications. Baseline data (mean, range) included annual lost school days (7.4, 0-100), lifetime ED visits (6.9, 0-100), hospitalizations (1.6, 0-35) and oral steroid courses (4.4, 0-60). Skin testing revealed 83.6% with at least one positive test (54.3% + cockroach and > 40% + to mouse, tree and dust mite). For the 114 children seen for > 3 visits the # of school days missed decreased to an average of 2.6/year. Mean annual ED visits for this group were 0.58 (range 0-8), hospitalizations 0.07 (range 0-3) and oral steroids 0.72 (0-11). Asthma severity decreased from > 50% moderate/severe at baseline to 71.8% mild after >3 visits with 89% on controller medications. CONCLUSIONS: During the first 2 years of the program, the Baltimore Breathmobile has seen increased use of controller medications, decreased missed school days and decreased asthma morbidity. Funding: Maryland Tobacco Restitution Fund

Patterns of quick-relief and long-term controller medication use in pediatric asthma

To simultaneously examine adherence to long-term controller and quick-relief medications and to contrast patterns of medication use in children with asthma. Cross-sectional, 1-month follow-up study conducted with 75 children ages 8 to 16 years diagnosed with persistent asthma and prescribed quick-relief and long-term controller medications by metered dose inhaler. Participants were a subsample of a larger adherence study. The primary outcome measure was adherence to both medications as measured by electronic monitoring devices. A classification framework for contrasting adherence patterns between medication classes was developed to identify cases for individual analysis. High levels of nonadherence to long-term controller medications (median = 46% of prescribed doses taken) and variable patterns of quick-relief medication use (range = 0 to 251 doses over the month) were documented, whereas consistent relationships between patterns of medication use across both classes were not found. Individual cases identified by the classification scheme illustrated the complexity and clinical utility of contrasting adherence patterns. Monitoring long-term controller medication adherence may be more predictive of morbidity than quick-relief medication use, except in outlier cases in which monitoring both medication types may be valuable for clinical and empirical purposes.

An infant with persistent wheezing due to non-acidic esophageal reflux

RATIONALE: We report the case of an 18 month old girl who presented with emesis, gagging, chronic cough, and wheezing. Despite the use of aggressive anti-reflux and asthma controller medications, her symptoms persisted. This case exemplifies the need to utilize a combined multichannel intraluminal impedance and pH study (MII-pH) to evaluate both acidic and non-acidic reflux as potential contributors to the supra-esophageal morbidity found in some cases of persistent respiratory distress.

The Status of Asthma Control and Asthma Prescribing Practices in the United States: Results of a Large Prospective Asthma Control Survey of Primary Care Practices

Control of asthma symptoms is, unfortunately, not a reality for many people with asthma. Asthma control is an ongoing challenge, requiring a multidisciplinary treatment approach. The National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute published its Guidelines for the Diagnosis and Management of Asthma in 1997, but the extent of implementation of recommendations in physician's practices remains to be determined. We sought to determine if a systematic implementation of the NAEPP practice guidelines would impact physician's treatment decisions for patients with asthma. The Asthma Care Network is a large, national, point-of-care program developed to assist health care providers in the assessment and management of their patients with asthma. Outcome measurements for the program included level of asthma control, activity limitation, sleep disruption, use of rescue medications, use of controller medications, and urgent care services. A total of 4,901 primary care physicians at 2,876 practice sites enrolled more than 60,000 patients. Nearly three fourths of patients reported symptoms consistent with a lack of asthma control (mean 74%, range 69–81%). Approximately 68% of pediatric patients and 78% of adult patients reported limited activities due to asthma in the past week. Sixty-two percent of pediatric patients and 68% of adult patients reported more than two symptomatic days in the past week. Approximately 40% of the patients surveyed were not using controller therapy. The overall percentage of patients reporting uncontrolled asthma who were prescribed a controller medication increased from 60% to 81%, and the use of inhaled corticosteroids containing medications among these patients increased by 52%. As a result of the assessment of the patients' level of asthma control during the office visit, physicians changed their patterns of prescribing controller therapy in patients with uncontrolled asthma.

Participatory Decision Making, Asthma Action Plans, and Use of Asthma Medication: A Population Survey

Use of controller asthma medication and possession of asthma action plans remains suboptimal. Our aim was to investigate the association of the propensity of physicians to involve patients in their care (participatory decision-making style) and their asthma management in a representative population sample of 3015 adults. Current doctor-diagnosed asthma was reported by 393 (13.0%). People who rated their doctors as more participatory were significantly more likely to report more regular use of controller medications and possession of a written asthma action plan, but not less asthma morbidity. Possession of a written action plan was associated with more participatory interactions (OR 2.3; 95% CI 1.1–4.7, for upper tertile scores compared to lowest tertile); more severe symptoms (OR 4.8; 95% CI 1.7–13.0), being female (OR 2.2; 95% CI 1.2–4.3), those with higher education, and residence outside the metropolitan area (OR 2.1; 95% CI 1.1–4.0). Increasing patient participation in their own care is associated with better asthma management, independent of asthma symptoms. Longitudinal studies are needed to examine if increasing participation in decisions can also improve asthma outcomes.