National Asthma Education Prevention Program Research Articles

Individualized Household Allergen Intervention Lowers Allergen Level But Not Asthma Medication Use: A Randomized Controlled Trial

Environmental exposures to indoor allergens are major contributors to asthma symptoms, particularly in inner cities. The effectiveness of household allergen reduction as an adjunct to National Asthma Education Prevention Program guideline-based pharmacologic therapy in asthma has not been prospectively studied. To study the effect of individualized allergen reduction on ability to reduce asthma pharmacologic therapy over 40 weeks. We performed a randomized controlled trial to determine the effect of multifaceted indoor allergen avoidance measures on the ability to reduce asthma controller therapy in adults and children residing in New York City who were both sensitized and exposed to at least 1 indoor allergen. Asthma treatment and control were optimized in all subjects before randomization. A total of 125 subjects were randomized to receive individualized household allergen reduction and 122 received a sham intervention. Subjects in the intervention group significantly reduced all measured allergen levels (cat, dog, dust mite allergens in the bedroom, cockroach and mouse allergens in the kitchen and bedroom); those in the control group reduced only dust mite and mouse allergens in the bedroom and cockroach allergen in the kitchen. Participants in the intervention arm reduced National Asthma Education Prevention Program-based therapy from step 4.4 at randomization to 3.50 postintervention (range, 0-6); participants in the control arm reduced medication from step 4.4 to 3.4 (P= .76). There were no differences in other measured asthma outcomes. Targeted allergen avoidance measures do not allow for reduction in asthma pharmacologic therapy compared with usual care in patients already receiving optimal controller therapy.

Assessing asthma control

The goal of asthma therapy is to achieve and maintain good asthma control. By utilizing evidence-based guidelines recommended by the National Asthma Education Prevention Program Expert Panel-3 Report, nurse practitioners can improve assessment of asthma control, and ultimately improve asthma outcomes.

Adjusting Controller Medications in Children: Evidence for Step Up and Down Choices after EPR-3

Evidence regarding long-acting beta-agonist safety and specific step up and step down recommendations in children that have been published since the National Asthma Education Prevention Program Guidelines for the Diagnosis and Management Expert Panel Report 3 are reviewed. Despite several systematic reviews involving many thousands of patients, the safety of long-acting beta-agonists in children remains under debate. Although the role of inhaled corticosteroids has been well established in children, whether the ideal add on therapy should be a long-acting betaagonist or a leukotriene receptor antagonist, balancing efficacy with safety information, remains controversial. The ideal step down regimen to be used after asthma control has been achieved is similarly not well established. Additional research in children is needed to answer these questions, particularly in the youngest age groups. Keywords: Asthma, guidelines, leukotriene receptor antagonists, long-acting beta-agonists, pediatric, pharmacotherapy

National Asthma Education Prevention Program: Survey of Nurse Practitioners’ Knowledge, Attitudes, and Behaviors

IntroductionMuch has been written regarding poor physician adherence to the National Asthma Education, Prevention Program (NAEPP) guidelines, but no data are available regarding nurse practitioners (NP) adherence. This descriptive study compared NP adherence to figures reported for medical doctors (MDs) in the 2001 and 2007 analyses by Cabana and colleagues. MethodA national, cross-sectional survey approach was used to assess NP knowledge, attitudes, and behaviors regarding the NAEPP guidelines. The survey was adapted from Cabana’s 48-item questionnaire. ResultsNPs provided more prescriptions of inhaled corticosteroids (ICSs) to patients with daily symptoms than did physicians (NPs, 79%; MDs, 54%). Overall, compared with MDs, NPs reported higher adherence on three of the four NAEPP guideline components surveyed, two of which were statistically significant. DiscussionThis survey suggests that NPs have greater adherence to prescribing ICSs than do MDs. However, improved adherence still needs to be a goal for all providers because prescription of ICSs is the cornerstone of management of persistent asthma.

Quality-of-Life and Cost–Benefit Analysis of a Home Environmental Assessment Program in Connecticut

Background. The National Asthma Education Prevention Program's (NAEPP) Expert Panel Report 3 (EPR3) guidelines have stressed the need for environmental control measures for asthma, but there is limited evidence of their efficacy. Objective. To examine the effectiveness of an in-home asthma intervention program for children and adults in Connecticut, we conducted a panel study to analyze quality-of-life indicators for asthmatic patients and the cost–benefit relationship in preventive care versus acute care. Methods. The Asthma Indoor Reduction Strategies (AIRS) program was developed to reduce acute asthma episodes and improve asthma control through patient education and a home environmental assessment. Follow-up was conducted at 2-week, 3-month, and 6-month intervals. Measured quality-of-life indicators included number of unscheduled acute care visits, days absent from school/work due to asthma, times rescue inhaler used, and number of symptom-free days. Repeated measures analysis of variance (ANOVA) was used to determine whether significant differences exist in quality-of-life indicators at follow-up compared to that at the initial visit. Cost–benefit analysis was conducted by tabulating costs associated with physician office visits and emergency department (ED) visits due to asthma for children and adults separately. Results. Twenty percent of participants in the program met the criteria for well-controlled asthma, 16% for not well-controlled asthma, and 64% for very poorly controlled asthma. At 6 months follow-up, the mean number of unscheduled acute care visits, days absent from school/work due to asthma, and times rescue inhaler used in the past week decreased by 87%, 82%, and 74%, respectively, whereas the mean number of symptom-free days increased by 27% compared to the initial visit. Furthermore, the percent of participants with very poorly controlled asthma decreased from 64% at initial visit to 13% at 6 months follow-up. All changes were statistically significant at p < 0.05. A net savings of $26,720 per 100 participants was estimated at 6 months follow-up due to decreases in unscheduled acute care visits for adults and children. Conclusion. Significant improvement in quality-of-life and decreases in healthcare resource utilization and costs were found after implementation of the AIRS program in Connecticut.

Electronic Health Record–Based Decision Support to Improve Asthma Care: A Cluster-Randomized Trial

Asthma continues to be 1 of the most common chronic diseases of childhood and affects approximately 6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting. We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratified for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of office-based spirometry. Increases in the number of prescriptions for controller medications, over time, was 6% greater (P = .006) and 3% greater for spirometry (P = .04) in the intervention urban practices. Filing an up-to-date asthma care plan improved 14% (P = .03) and spirometry improved 6% (P = .003) in the suburban practices with the intervention. In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines.

A Comparison of an Individually Tailored and a Standardized Asthma Self-Management Education

Background: Asthma is one of the most prevalent chronic diseases in the United States and can be life-threatening. There are a rising number of adults with asthma that cannot be prevented or cured but may be controlled. Selfmanagement education is essential for long-term asthma control; however, the most effective type of education is unknown. Purpose: The study examined and compared effects of an individually tailored (n = 44) and a standardized (n = 44) asthma self-management program on adult asthma control. The individually tailored education utilized an andragogical framework. Methods: A comparative, pretest-posttest design was used. Education curricula were based on National Asthma Education Prevention Program guidelines. Asthma Control Test (ACT) and Peak Expiratory Flow readings were pre and post-test measures. Independent t-test, chi-square, and repeated measure general linear model compared groups. Results: A significant difference in ACT scores between pre and post-test (F = 4.43, p = 0.038) and a decrease in mean number episodes of shortness of breath (F =6.22, p = 0.015), regardless of asthma teaching method was found. Over 50% of participants reported not receiving previous asthma education. Physicians were the primary source of education reported. Discussion: Asthma education is needed. Both the standardized and individually tailored education may improve asthma control. Translation to Health Education Practice: Health educators must take an active role in providing asthma education based on the rising number of adults with asthma and reports of those receiving no education. Practitioners can determine the type of education based on the setting and learner needs.

Current Asthma Guidelines May Not Identify Young Children Who Have Experienced Significant Morbidity

The current guideline for classifying asthma severity, the National Asthma Education Prevention Program (NAEPP) 2002, is not evidence-based. We had the opportunity to validate this guideline in an untreated inner-city population, both in those < or =5 and those >5 years of age. The basis for this retrospective validation model was to determine how well the NAEPP severity classification based on symptom-frequency criteria alone identified patients in those age groups demonstrating significant morbidity the previous year and thus the potential need for controller therapy. Using a mobile asthma van (Breathmobile) at the school site, children not receiving controller medication were evaluated by an asthma specialist for severity according to NAEPP guideline clinical criteria. Validation was determined by the relationship of guideline severity to > or =2 emergency department (ED) visits, any hospitalization, health care utilization (any ED visit, hospitalization), number of exacerbations, and school absenteeism resulting from asthma the prior year. Eight hundred twenty-six asthmatic children were evaluated; 89 (10.8%) were < or =2 years, 222 (26.9%) were 3 to 5 years, and 515 (62.3%) were >5 years of age; 60.5% were male, and 80.9% were Hispanic. Classification of asthma severity included 34.4% with mild intermittent, 10.2% with mild persistent, 31.5% with moderate persistent, and 24.0% with severe persistent asthma categories. There were significantly more Hispanic children and children < or =5 years classified as having mild intermittant asthma. Morbidity was clearly related to severity in the overall population. However, although the health care utilization was significantly related to severity, it was borderline in those 3 to 5 years and nonsignificant in children < or =2 years. The NAEPP guidelines 2002, based on symptom-frequency criteria as assessed in this study, seem to offer a valid basis for classifying asthma severity in those >5 years of age but may underclassify younger children. Our data suggest that morbidity experienced in the prior year may provide a useful additional criterion for classifying asthma severity, particularly in those children < or =5 years of age.

Practical approaches to treating acute bronchospasm.

Both the National Asthma Education Prevention Program (NAEPP) guidelines for asthma and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD) stress the importance of treating acute bronchospasm. Important steps for each disease are making a differential diagnosis, assessing the possibility of future exacerbations, applying disease management principles to prevent and/or treat bronchospasm exacerbations, identifying acutely ill patients, and determining when hospitalization or specialist referrals are appropriate.

Measuring asthma disparities in Hispanics: adherence to the national guidelines for asthma treatment in emergency departments in Puerto Rico

Puerto Rico has the highest prevalence of asthma in the United States. Currently, there are no data on actual care given to asthmatic patients. To determine the prevalence of documented adherence to the 1997 National Asthma Education Prevention Program guidelines regarding care given in emergency departments (EDs) in Ponce, Puerto Rico. A case series was conducted using 6,002 ED records with a physician-based diagnosis of asthma for 1999 through 2001. A history of asthma attack was documented in 82.0% of the cases and in all age groups. In-home beta-agonist use was recorded in only 5.7% of the medical records. Documentation of previous admissions to the ED and the intensive care unit were found in 3.5% and 0.33% of the records, respectively. Nocturnal symptoms before the ED visit were found in only 6.4% of the records, and asthma treatment at home was found in 39.9%. Accessory muscle retraction was documented in 99.1% of the cases, and oxygen saturation was found in 23.2%. Treatment with nebulized beta-agonist was found in 72.1% of the records, and intravenous or oral corticosteroid use was found in 84.1%. Follow-up appointments were detected in 64.8% of the cases, and referrals to specialists were given in only 5.3%. Rate ratios between our data and those of other researchers indicate that there are geographical differences in compliance with the guidelines. Of the variables tested, only one had acceptable levels of compliance, as evidenced in the patient's records, indicating that there are alarming differences in ED evaluation and treatment compared with the 1997 National Asthma Education Prevention Program guidelines.

Asthma care in the internal medicine (IM) clinic of a community hospital

Rationale Despite the availability of specific guidelines for asthma care from the National Asthma Education Prevention Program (NAEPP) in 1991 and 1997, there is little evidence that asthma education has positively influenced management by primary care physicians. We examined IM resident compliance with these guidelines and whether education based on the 1997 update led to improved asthma care. Methods From June 2000 to June 2002, we identified 219 charts of patients discharged from the IM resident clinic with ICD-9 codes for asthma. Of these, 106 were randomly selected. Twenty-nine charts were excluded because of insufficient data or acute care visits only. The remaining seventy-seven charts were analyzed for quality of care according to NAEPP guidelines. Results Asthma severity was classified in only 10% of charts. Peak flow measurements were recorded in 19% of charts. Inhaled corticosteroids were prescribed to 53% of patients. An identical study conducted by our group in 1996-97 (JACI 2003;111(2):S162) examined similar variables in resident management of asthma patients. Of twenty-five variables that were analyzed in both studies, only 5 showed statistically significant improvement. Conclusions Resident education based on the results of our previous study and the newer (1997) guidelines resulted in minimal improvement in asthma management in our clinic.

Effectiveness of Acute Asthma Care Among Inner-city Adults.

Acute asthma often requires expensive emergency department visits and hospitalizations, especially among economically disadvantaged inner-city adults. However, few studies have examined approaches for improving acute asthma care in this population. We conducted a cohort study involving patients who were discharged from a public hospital emergency department following acute asthma care between March 31, 1997, and August 5, 1999, to identify processes of care effective for improving peak expiratory flow rate at a 2- to 3-week follow-up. Adult patients who met the predetermined criteria for asthma, who underwent a baseline peak expiratory flow rate reading, and who did not have concurrent acute sinusitis or pneumonia were eligible (N = 448). Of the 365 patients enrolled in the study, 309 (84.7%) completed it. We used a multiple linear regression analysis adjusted for patient risk to assess the association between acute asthma care processes derived from the National Asthma Education Prevention Program guidelines (inhaled beta2-agonists, inhaled corticosteroids, systemic corticosteroids, asthma care follow-up, and patient asthma education) and percentage peak expiratory flow rate change at follow-up. Systemic corticosteroids had a significant effect for increasing percentage peak expiratory flow rate change at the 2- to 3-week follow-up for all asthma exacerbation severity levels (beta = 26.1; 95% confidence interval, 1.8-50.5; P =.04) and severity levels specified by the National Asthma Education Prevention Program guidelines (beta = 31.6; 95% confidence interval, 8.1-55.1; P =.01). Outpatient systemic corticosteroids were effective for improving lung function 2 to 3 weeks after acute asthma care, and their use should reduce asthma-related morbidity, especially among economically disadvantaged inner-city adults.

Underutilization of controller and rescue medications among older adults with asthma requiring hospital care.

Asthma causes serious morbidity in older people, but pharmacologic therapy in older people with asthma has never been studied, at least in part because of the difficulty of defining asthma in this population. To determine if older persons enrolled in Medicaid and hospitalized with an exacerbation of asthma receive appropriate outpatient asthma care. Descriptive pharmacoepidemiology of a group of older adults with asthma. The Tennessee Medicaid Program. Persons aged 65 and older, enrolled in the Tennessee Medicaid program, identified through Medicaid's computerized database as having a hospital care visit for asthma in 1992 and who had their diagnosis confirmed by chart review. Medication utilization. The source population included 93,686 persons aged 65 or older enrolled in the Tennessee Medicaid program. The group meeting study criteria included 512 patients with chronic asthma who had a hospital care visit for an asthma exacerbation. Eighty-one percent of these 512 persons with an asthma hospitalization confirmed by chart review were classified as having moderate to severe or potentially fatal asthma. These patients had had a median of 15 outpatient visits in the previous year, and more than half of them had an outpatient visit in the 14 days before their hospitalization. However, among those with moderate to severe or near fatal asthma only 25% filled prescriptions for inhaled corticosteroids, whereas 52% were taking theophylline, the most commonly prescribed asthma medication in this group. There was also high use of antibiotics (29%) and low use of rescue corticosteroids (5%) before the hospital care visit, despite frequent medical encounters. Despite widespread promulgation of the National Asthma Education Prevention Program guidelines, our study suggests that providers caring for indigent older subjects with moderate to severe or potentially fatal asthma were not following these guidelines. There was significant underutilization of inhaled anti-inflammatory agents, beta-agonists, and rescue corticosteroids in this population despite frequent outpatient medical care visits.

The Lawndale Christian Health Center Asthma Education Program

The National Asthma Education Prevention Program Expert Panel Report 2 guidelines describe four components necessary for an effective asthma management program. The fourth component emphasizes that “education for active partnership with patients remains the cornerstone of asthma management.” 1 National Asthma Education and Prevention Program Expert panel report 2: guidelines for the diagnosis and management of asthma. National Institutes of Health, Bethesda, MDApril 1997 Google Scholar Lawndale Christian Health Center (LCHC) has developed an asthma education program that emphasizes the importance of developing trusting relationships leading to partnerships that can result in effective education.

How the Discrepancy between Symptoms and Peak Expiratory Flow Rate Influences Evaluation of Asthma Severity

Recent asthma guidelines recommend the assessment of severity levels based on the most severe symptoms and peak expiratory flow rate (PEFR). Discrepancies are frequently encountered in the use of these variables in determining the severity levels of asthmatics. The objective of this study was to determine the difference in asthma severity levels as assessed by either symptoms alone or by PEFR alone, as compared with the assessment by the asthma guidelines. Severity levels that were determined by recent asthma guidelines for 60 asthmatic patients were reassessed, based on symptoms alone and PEFR alone. They were compared for any significant differences to the asthma guidelines. Asthmatics were aged between 15 and 70 (mean 34) years, and 63.8% were females. Severity levels by symptoms alone were different from the guidelines in 27 cases (45%). Of these, 89% showed a tendency toward higher severity levels. Severity levels by PEFR alone were different in only three cases (5%). In both comparisons, differences of severity levels were significant (P<0.0001), but assessment by symptoms alone showed more deviation (x(2) =162.1) than PEFR alone (x(2) =73.1). The study documented significant discrepancies in asthma severity assessed by symptoms alone and PEFR alone, when compared to the recent asthma guidelines. Severity assessed by symptoms alone showed lower levels, and the use of PEFR tended to categorize some asthmatics into a more severe level.