Evidence-based Asthma Guidelines Research Articles

Benefit of pulmonary subspecialty care for children with sickle cell disease and asthma.

Asthma is a recognized comorbidity in children with sickle cell disease (SCD). It increases the risk of acute chest syndrome (ACS), vaso-occlusive episodes, and early mortality. We aim to determine whether evaluation and management of children with SCDand asthma by a pulmonologist reduce rate of asthma exacerbation and ACS. The study included 192 patients with SCD (0-21 years) followed at Children's Hospital of Philadelphia Hematology between January 1, 2015, and December 31, 2018, with a diagnosis of asthma, wheeze, or cough. Patients were placed in two groups: those evaluated by a pulmonologist (SCD-A-P) and those not (SCD-A). Rates of emergency department (ED) visits and hospitalizations for asthma exacerbation and ACS were compared between groups and over time. SCD-A-P patients (n = 70) were predominantly SCD type SS with lower hemoglobin and hematocrit compared to SCD-A patients (n = 122). SCD-A-P started with a higher average rate of hospital visits for asthma exacerbation and ACS per year (2.69 [1.02-4.37]) compared to SCD-A (0.43 [0.24-0.63]), (p < 0.001). For SCD-A-P patients with at least one hospital visit (n = 48), the average rate decreased from 3.93 (1.57-6.29) to 0.85 (0.48-1.23) following pulmonary consultation (p = 0.014) and was comparable to the SCD-A rate by study end. SCD-A-P was mainly SCD type SS and had higher ED/hospitalization rates for asthma exacerbation and ACS compared to SCD-A, but the rates significantly decreased following pulmonology consultation. These findings support the pulmonologist's role in the multidisciplinary care of SCD patients and highlight the need for evidence-based asthma guidelines for children with SCD.

Forthcoming UK asthma guidelines: an opportunity to improve asthma outcomes

The UK has a strong tradition of providing excellent, evidence-based asthma guidelines,1 and a totally inglorious one of having some of the worst asthma outcomes in the world.2 Addressing these poor outcomes must top the agenda for those taking forward the forthcoming UK National Institute for Health and Care Excellence (NICE), British Thoracic Society (BTS), and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the diagnosis, monitoring, and management of chronic asthma.3 The challenge for the group developing these guidelines is to think radically, and produce a document that drives real change in outcomes, including mandating sanctions for non-compliance with new clinical practice recommendations.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools

Objective To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma. Methods Students 4–14 years old with persistent asthma were enrolled from three SBHCs. The centers’ advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers’ providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care. Results We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV1% predicted and FEV1/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively). Conclusions Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes. Trial Registration clinicaltrials.gov Identifier: NCT03032744

Providers' Adherence to Evidence-Based Asthma Guidelines in Pediatric Primary Care

BackgroundRegardless of existence of National asthma guidelines, adherence to major elements of guidelines among providers is suboptimal. The nonadherence contributes to poor clinical outcomes and quality of life of asthma patients. PurposeThis project aims to improve the standard of care of asthma patients with increased providers' adherence to asthma guidelines through provider education, and implementation of practice guidelines and evidence-based resources. MethodsA pre-post implementation retrospective design was adopted along with the provision of provider education sessions and implementation of pediatric asthma management practice guidelines and asthma resources in the pediatric practice in Southern, New Jersey. Data were collected via retrospective chart review among 41 patients four-months pre-implementation and 38 patients three months post-implementation to assess the improvement of providers' adherence to seven elements of asthma guidelines. Descriptive statistics and chi-square tests were computed to evaluate providers' adherence. ResultsResults showed improvement from pre- to post-implementation in utilization of six of the seven key elements of guidelines among providers that include, the assessment and documentation of asthma control (4.9% to 39.5%), medication adherence (20% to 87.5%), medication delivery technique (7.3% to 18.4%), environmental triggers (14.6% to 44.7%), asthma action plan (4.9% to 28.9%), and follow-up visits (48.8% to 76.3%). In addition, the chi-square test showed a significant association between environmental triggers assessment from baseline to post-implementation, χ2 (1, n = 79) = 4.29, p = .038. ConclusionProviding necessary resources and provider-focused education demonstrated a positive change in promoting best practice and facilitating providers' adherence.

Asthma in the USA: the good, the bad, and the disparity

Asthma in the USA: the good, the bad, and the disparity

Provider Adherence to Evidence-Based Asthma Guidelines in a Community Health Center.

Background: Improved outcomes for patients with asthma have been proven with the use of the Expert Panel Report 3 (EPR-3) evidence-based asthma guidelines. These clinical guidelines are tools developed for providers to direct appropriate high-quality patient care that leads to positive outcomes. However, research has shown health care providers do not routinely follow the evidence-based asthma guidelines adequately. Objective: To develop and implement an evidence-based asthma protocol in a community clinic and improve provider adherence and attitudes/beliefs to the EPR-3 guidelines resulting in improved asthma outcomes, asthma control, and self-management for patients with asthma. Methods: The study was conducted in 2 parts over a period of 3 months. First, all medical providers at a community clinic were invited to participate in the research study. The intervention included implementing the asthma protocol within the current electronic health record (EHR). A pre- and postintervention questionnaire measuring provider's adherence and attitudes to evidence-based practice was administered. In addition, pre- and postclinic aggregate data for International Classification of Diseases codes specific to asthma that correlate to 7 identified aims based on the EPR-3 guidelines were collected. Results: Results show statistical significance among the provider attitudes/beliefs with the intervention, the greatest effect being found for the medical doctors. Four of the 7 aims showed improvement. Conclusions: The findings of this application research quality improvement study indicate that providing necessary tools and resources needed to adhere to evidence-based asthma guidelines can positively affect providers' adherence and attitudes/beliefs toward evidence-based guidelines.

Wissen von Hausärzten und Ärzten in Weiterbildung über nationale Asthmaleitlinien

In Germany as well as internationally, evidence-based asthma guidelines were developed as a decision aid for diagnosis and therapy. However, adherence to recommendations is usually less than optimal. The authors explore potential implementation barriers: knowledge gaps, practical presentation of guidelines, and attitudes of doctors and patients. In this paper, we compare results of our knowledge survey of family doctors and trainees with results of similar national and international studies. In all studies, all surveyed groups of physicians revealed considerable knowledge gaps. Many physicians in our own study erroneously preferred mucolytics and antibiotics to treat acute or subacute asthma symptoms though these drugs are not or only exceptionally indicated. The inflammatory character of asthma often goes unrecognized, as well as the importance of inhaled (and systemic) corticosteroids in long term treatment (or treatment of exacerbations).

Efficacy versus effectiveness trials

Randomized controlled trials, known as efficacy trials and long considered the gold standard for evidence-based asthma guidelines, are designed to test whether interventions have a benefit for selective patient populations under ideal conditions. The goal of pragmatic trials and observational studies instead is to understand real-life efficacy, known as effectiveness. This review summarizes the strengths and limitations of efficacy and effectiveness trials, results of recent effectiveness trials in asthma and initiatives promoting effectiveness research. Recent pragmatic trials and observational studies have examined outcomes of interventions for diverse real-life patient populations, including smokers and patients with variable adherence, inhaler technique and baseline asthma control. Study results challenge practice guidelines regarding relative effectiveness of leukotriene receptor antagonists and inhaled corticosteroids (ICS); supplement guidelines with regard to effectiveness of interventions in smokers; and begin to address gaps in guidelines regarding choice of ICS and inhaler device. Initiatives are ongoing to refine methods of observational research and to harmonize asthma outcomes for better integration of results from all types of trials. Results of pragmatic trials and observational studies are an important component of the evidence needed to inform guideline recommendations and decision-making by healthcare providers, patients and policymakers.

Meta-analysis of Serious Asthma-related Outcomes in Subjects Receiving Advair®

RATIONALE: Evidence-based asthma guidelines recommend adding a LABA as preferred therapy in adults and children uncontrolled on ICS alone. The guidelines also state that for asthma, a LABA should always be used concurrently with ICS.

Acute Effects of Passive Smoking on Asthma in Childhood

Although evidence-based asthma guidelines report passive smoke exposure as one of the triggers of asthma symptoms and exacerbations, its prevelance is still high among children with asthma especially in those coming from low income families. Passive smoke exposure affects different aspects of asthma control not only diurnal and nocturnal symptoms and exacerbations but also rescue medication use and lung functions as well as bronchial hyperreactivity, school absenteeism and quality of life. Immediate effects of passive smoke exposure in all these asthma parameters seem to be additive to those of chronic exposure. Smoking cessation interventions therefore play a pivotal role for a better asthma control.

Implementation of Evidence Based Guidelines for Paediatric Asthma Management in a Teaching Hospital

Massie J, Efron D, Cerritelli B, et al. Arch Dis Child. 2004;89:660–664To evaluate a systemic and coordinated approach to the development and implementation of evidence-based asthma guidelines for a pediatric hospital.This was a comparative study conducted at the Royal Children’s Hospital in Melbourne, Australia. There were 3 cohorts of children evaluated between the ages of 2 and 18 years who presented with acute asthma to the emergency department. Cohort 1 presented before the development of asthma guidelines, cohort 2 was recruited to assess the effectiveness of guideline implementation, and cohort 3 was recruited 1 year later to assess the sustainability of guideline changes.The Royal Children’s Hospital best-practice guidelines for the care of asthma were established after careful review of established national/international guidelines and consideration of evidence-based reviews in the literature. The guidelines also took into consideration recommendations from Improving Child and Adolescent Asthma Management members. There was a detailed launch of the guidelines in the institution, with a major focus on implementation of the guideline recommendations through a variety of vectors. The primary outcome measures of this study were rates of reattendance and readmission to the hospital, a change in asthma morbidity, and quality of life.There were 374 children in cohort 1, 363 in cohort 2, and 377 in cohort 3. There was no difference in baseline characteristics between the cohorts (age, gender, asthma severity). There was no statistically significant difference in the proportion of patients who revisited the emergency department or were admitted to the hospital between the 3 groups within 6 months of the initial presentation (21–27% for revisits to the emergency department and 11% rehospitalization). There also were no differences in measures of morbidity between the cohorts across 3 domains (interval symptoms, exercise compromise, and bronchodilator usage) or in parent or child quality-of-life scores between the groups. However, there was a significant increase in those who were given asthma-management plans with the implementation of the practice guidelines.The implementation of evidence-based guidelines made no difference in readmission to the hospital, return visits to the emergency department, asthma morbidity, or quality of life but did increase the provision of asthma-management plans. The authors concluded that future efforts to improve asthma management should target specific components of asthma care.Certainly the results of this study are disappointing, especially for those of us who develop, implement, advocate, and teach guidelines. Were the guidelines at fault? Were the guidelines implemented properly? Were they carried through for both sides of the illness, and if so, for how long? It was not clear what went on after the first encounter. Was there appropriate follow-up with guideline-savvy primary caretakers who were able to emphasize the guidelines? My guess is that perhaps more emphasis and more “implementation” is needed more frequently at the patient/caretaker level, and I would not give up on guidelines just yet.

A Training Program for Certified Asthma Educators: Assessing Performance

Background. Evidence-based asthma guidelines identify asthma education as an essential element of care. In Canada, a process for certifying asthma educators was established to help provide asthma education to patients. A critical component to certifying asthma educators is their training and evaluation. The purpose of the study was to identify an approach to evaluate participants and to determine if specific characteristics influenced participants' success. Methods. Participants completed a questionnaire that collected demographic, practice, and learner characteristics. Assessment strategies and criteria used to determine the level of success included 1) a written asthma knowledge score; 2) a written educational theory score, and 3) a practice teaching skill score based on three encounters with standardized patients. Standardized patient encounters were scored by using a standard checklist of essential teaching functions. Results. Participants (n = 73) represented a broad range of health professions (respiratory therapists, nurses, pharmacists, and physiotherapists). The average score for written asthma knowledge, educational theory, and practice skill assessment was 82.0 ± 8.0%, 68.6 ± 16.2%, and 80.3 ± 9.7%, respectively. Moderate interrelationships were observed between the practice teaching skills score and years of practice in asthma (r = 0.35; p< 0.01) and percentage of workdays dedicated to asthma care (r = 0.30; p< 0.05). Moderately strong relationships were observed among the three standardized patient encounters. However, there were no associations between participant scores on the written asthma or educational theory examination and the practice skill assessment scores. Conclusions. Participants of an asthma educator training program represent a wide range of disciplines, practice settings, and experience. It is important that asthma educator training programs assess both written knowledge and practice assessments to evaluate participants.