Prevention Program Guidelines Research Articles

Emergency department discharge asthma action plans improve controller medication compliance in persistent asthmatics

Study objectives: The National Institutes of Health National Asthma Education and Prevention Program guidelines recommend chronic use of controller medications such as inhaled corticosteroids for all persistent asthmatic patients (step II or higher). Previous studies have demonstrated poor compliance with controller medication use in emergency department (ED) asthmatic patients. The purpose of this study is to determine whether discharging patients with a written asthma action plan from the ED will improve long-term compliance with controller medications. Methods: A prospective, grant-funded study of ED wheezing patients has been in place since November 2002. In phase II of this study, prospectively enrolled wheezing patients older than 12 months were treated for acute wheezing in an unrestricted fashion. For those discharged from the ED, parents were given a written asthma action plan along with other optional educational tools such as an asthma educational video while in the ED. Patients were later contacted by telephone to assess use of controller medications. Results: Of the 719 encounters (596 subjects) enrolled in phase I, 68 (9%) had written asthma action plans. Three hundred ninety-five encounters were assessed as persistent (step II or higher), and of these, 15% were using controller medications correctly, 12% were using controller medications intermittently, and 73% were not receiving controller medications. Two hundred forty-six patients were interviewed by telephone 2 to 4 weeks after the ED visit, and of these, 14% were using controller medications and 86% were not. The ED encounter alone failed to increase the appropriate use of controller medications. Among the first 160 patients enrolled in phase II, only 15 patients had written asthma action plans at the ED visit. One hundred fifty-two patients received a color-coded written asthma action plan on ED discharge, which clearly recommends inhaled corticosteroids even during well periods (color coded as green). For the 78 patients assessed as persistent asthmatics (step II or higher), the appropriate use of controller medications improved 2 to 4 weeks later, assessed during a telephone interview compared with controller medication use before the ED visit as follows: using controller medications appropriately (41% versus 18% previously), using controller medications intermittently (13% versus 21% previously), and not using controller medications at all (46% versus 62% previously). Conclusion: Appropriate controller medication compliance rates have increased with the interventions initiated in phase II of this study. The most consistent intervention in this cohort is a written asthma action plan provided from the ED. Although the long-term management of a chronic disease such as asthma is more optimally managed by primary care physicians, asthmatic patients who utilize the ED might have poorer access to or poorer compliance with primary care, and for these reasons, methods to improve long-term controller medication compliance can be enhanced by educational tools such as written asthma action plans provided by the ED and are faster and preferable.

Effect of deep inspiration on airway caliber in children with asthma.

The objective of this study was to assess the effect of deep inspiration (DI) on airway caliber in school-age children with asthma. Thirty children with asthma (10 from each group of mild, moderate, and severe persistent asthma as defined by the National Asthma Education and Prevention Program guidelines of the National Heart, Lung, and Blood Institute) were enrolled, and their results were compared to those obtained in 7 healthy children. Subjects performed a partial expiratory flow volume curve (P) initiated from approximately 70% of vital capacity (VC) followed by a maximal expiratory flow volume (M) maneuver begun from total lung capacity (TLC). The M/P ratio at 30% of the VC (M/P30) was calculated. Specific airway conductance (sGaw) was measured before and immediately after DI, using standard techniques. Differences in M/P30 and sGaw ratios between asthma and control groups were compared with Student's unpaired t-tests. One-way ANOVA was used to compare the effect of DI on M/P30 and sGaw ratios among the various asthma severity groups. The M/P30 ratio (mean +/- 1 SD) was significantly lower in children with moderate and severe persistent asthma (0.73 +/- 0.21 and 0.72 +/- 0.1, respectively) than in healthy controls (1.69 +/- 0.62) (P < 0.05). In mild persistent asthmatics, there was limited bronchodilation (M/P30 = 1.1 +/- 0.35, P = 0.052). There was a significant inverse correlation between M/P30 ratio and severity of asthma (r = -0.684, P < 0.01). The mean sGaw ratio was decreased in asthmatic subjects compared to healthy controls (0.98 +/- 0.17 vs. 1.13 +/- 0.16, P = 0.062). In conclusion, in school-age children, the effects of DI on airway caliber are similar in direction to those observed in adults, i.e., bronchodilation in healthy and mild asthmatics, and bronchoconstriction (BC) in moderate to severe asthmatics. This finding suggests that forces that determine airway caliber in school-age children are similar to those forces in adults.

Impact of coping and socioeconomic factors on quality of life in adults with asthma

The socioeconomic variables of income, race and employment status have been shown to influence health-related quality of life (HRQL) scores in persons with asthma. However, little is known about the impact of other psychological factors or perceptions of economic hardship on HRQL in asthma, despite the known influence these have on general activity levels and emotional perceptions. The aim of the present study was to assess the relationships between psychological and socioeconomic factors and HRQL and on subsequent changes to HRQL over 12 months. Consecutive adult patients with moderate or severe asthma attending outpatient clinics, emergency departments or who were inpatients at two teaching hospitals, completed surveys of clinical status, psychological and socioeconomic variables, and HRQL instruments (SF-36 and Modified Marks Asthma Quality of Life Questionnaire [MAQLQ-M]), at baseline and over 12-months follow-up. Of 343 eligible subjects, survey responses were received from 293 at baseline and 232 at 12-months. Mean age was 42 years (SD 18), 67% were female, 42% had moderate, and 58% severe current asthma clinical status according to the National Asthma Education and Prevention Program guidelines criteria. In random-effects multiple regression models, after adjusting for age, gender, education, income and hospital, significant independent variables associated with each of total MAQLQ-M, SF-36 Physical Component Summary (PCS) and SF-36 Mental Component Summary (MCS) scores were avoidance coping, perceived recent financial difficulties and clinical asthma status. Additional independent associations were, for total MAQLQ-M, patient concerns about costs delaying them from seeking care (overall model r(2) = 0.69); for PCS, active coping (r(2) = 0.69) and for MCS, positive evaluations/satisfaction with illness (r(2) = 0.54). Psychological factors, particularly coping styles, need to be taken into account when considering HRQL scores as outcome measures in asthma. Interventions to improve the coping capabilities of individuals with moderate-to-severe asthma may be potentially important areas for improvement of asthma-related HRQL.

Sub-optimal asthma treatment and symptom control in senior citizens with a diagnosis of asthma

Rationale As the U.S. population ages, asthma in the elderly is an increasing problem. Several studies suggest that asthma is under-diagnosed and under-treated in elderly populations. Our study assesses asthma treatment and symptom control using National Asthma Education and Prevention Program (NAEPP) guidelines in a population of asthmatics 60 years and older. Methods A 75 question asthma specific survey was mailed to participants in the Aging Research Registry of Northwestern University's Buehler Center on Aging. Results Surveys were mailed to 171 registry members ages 60 and older who identified themselves as having asthma or allergies. One hundred and twelve (65%) responded to the survey, of which 35 (31%) reported a diagnosis of asthma. Only participants with a diagnosis of asthma were included in the study. The mean age of the respondents was 76 years of age. Eighty-three percent of the respondents were women, 17% were men, 89% were white, and 11% were black. Using NAEPP guidelines, 15 (43%) of the respondents had poorly controlled asthma based on nocturnal symptoms or frequent albuterol use. Of those with poor symptom control, 6 (40%) were not on an inhaled corticosteroid and 8 (53%) were not on a long acting beta agonist. Conclusions Our results suggest that 40% of senior citizens with asthma have poor symptom control. In addition, nearly half of seniors with poor symptom control do not appear to meet NAEEP treatment guidelines. These data are consistent with findings in children and younger adults who frequently have less than recommended treatment.

Disfonia em professores do ensino municipal: prevalência e fatores de risco

A disfonia é um sintoma muito freqüente em professores, profissionais para os quais a voz é elemento indispensável. OBJETIVOS: Observar a prevalência deste sintoma em professores de pré-escola e da escola primária e avaliar fatores e sintomas associados, facilitando a promoção de medidas de prevenção desta manifestação ocupacional. FORMA DE ESTUDO: Coorte transversal. CASUÍSTICA E MÉTODO: Estudo transversal consistindo de questionários respondidos por 451 professores (pré-escola e quatro primeiras séries do ensino fundamental) de 66 escolas municipais de Mogi das Cruzes. Ao lado de dados de identificação e demográficos, o questionário abordou questões relacionadas à atividade de professor, à disfonia, presença de sintomas concomitantes e hábitos. Trinta profissionais com problemas constantes de voz foram submetidos a telescopia laríngea, sendo seus diagnósticos tabulados. RESULTADOS: 80,7% dos professores referiram algum grau de disfonia. Não observamos relação entre idade, tempo de profissão e classe atendida e freqüência referida de disfonia. Não houve associação entre freqüência de disfonia e número de fatores extra-profissionais de abuso da voz ou tabagismo. Observamos relação direta entre a freqüência de disfonia e a carga horária semanal (p &lt; 0,01) e o número de alunos por classe (p &lt; 0,02), além de associação significativa com presença de sintomas de rinite alérgica (p &lt; 0,001) e refluxo gastro-esofágico (p &lt; 0,01). O diagnóstico laringoscópico incluiu, ao lado de lesões características de esforço vocal, alterações congênitas e outras etiologias. CONCLUSÕES: A disfonia mostrou elevada prevalência em professores. Medidas preventivas devem contemplar a redução da carga horária e do número de alunos por classe, bem como o tratamento de afecções concomitantes.

Pediatric Asthma Care, Polypharmacy

Pediatric Asthma Care, Polypharmacy

The role of the immune system in the pathogenesis of asthma and an overview of the diagnosis, classification, and current approach to treating the disease.

To describe what is currently known about the role of allergy and immunologically active cells and mediators in the airway inflammation associated with asthma; to review the diagnosis, classification, and treatment of the disease in accordance with current National Asthma Education and Prevention Program guidelines published in 2002; and to discuss therapeutic issues related to asthma management. This article is based on a presentation given by the author at a symposium entitled. New Frontiers in Asthma Management: Biotechnology for Optimal Therapeutic and Economic Outcomes. at the Academy of Managed Care Pharmacy's 15th Annual Meeting and Showcase in Minneapolis, Minnesota, on April 10, 2003. Type 2 helper T (Th2) cells, various other cell mediators and cytokines, and immunoglobulin E play important roles in the pathogenesis of asthma. Atopy is an inherited condition characterized by a predominance of Th2 cells and it predisposes to asthma. Objective measures of pulmonary function improve confidence in the diagnosis of asthma and should be used to monitor response to therapy. Asthma severity is often underestimated by patients and physicians, which can lead to inadequate treatment. Inhaled corticosteroids (ICSs) are the preferred maintenance treatment for patients with persistent asthma because these medications are the most potent and effective long-term controller pharmaceutical agents. Addition of a long-acting inhaled beta2-agonist or a leukotriene modifier to ICS therapy provides added benefit to patients with moderate or severe persistent asthma inadequately controlled by corticosteroids. Choosing an appropriate delivery system for inhaled drug therapies can affect patient adherence and the effectiveness of therapy.

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.

Physician Specialty as a Key Determinant of Guidelines-Based Asthma Car

PURPOSE: National Asthma Education and Prevention Program (NAEPP) guidelines recommend therapy based on structured severity stratifications for each patient, and written action plans with self-monitoring of peak flows. Nevertheless, many patients do not receive guideline-based care. This study surveyed physicians treating asthma patients to identify significant differences in guidelines-based care across specialties.

Comprehensiveness of substance use prevention programs in U.S. middle schools.

To assess how current practice in middle school substance use prevention programs compares with seven recommended guidelines adapted from the Centers for Disease Control and Prevention guidelines for school-based tobacco use prevention programs. Substance use prevention practice was analyzed using data from a 1999 mailed questionnaire of a nationally representative sample of 1496 public and private schools with middle school grades that reported having a substance use prevention program. Respondents answered questions about substance use prevention education and activities in the whole school and in their own classroom. Weighted prevalence estimates for the seven recommendations are presented, and multiple regression was used to analyze correlates of implementation of the recommendations. An estimated 64.2% of schools met four or more of the recommendations for school-based substance use prevention practice; 4.0% met all seven recommendations. Schools were most likely to report having and enforcing substance use prevention policies (84.3%) and least likely to report training teachers in substance use prevention (17.9%). More recommendations were implemented in schools that were public and had larger enrollments, greater perceived availability of resources, greater school board and parental support for substance use prevention, and had hired a school substance use prevention coordinator. The low prevalence of comprehensive substance use prevention programs in U.S. middle schools may limit the potential impact of school programs on the prevalence of youth substance use.

Multicolored simplified asthma guideline reminder (MSAGR) for better adherence to national/global asthma guidelines

Clinicians in general have not widely and consistently used asthma guidelines in their practices around the world. This study identifies reasons for the poor adherence to asthma guidelines by primary care physicians (PCPs), and simultaneously introduces multicolored simplified asthma guideline reminder (MSAGR) as a practical tool to enhance adherence to asthma guidelines. Sixty-nine PCPs were given a simple, one-page, fill-in-the-blank questionnaire on the classification of asthma severity as defined in National Asthma Education and Prevention Program guidelines, using patients' symptoms, peak expiratory flow rate (PEFR)/forced expiratory volume in 1 second (FEV1) value, PEFR variability, and step therapy based on asthma severity. Also, they were given a questionnaire on barriers to using asthma guidelines and MSAGR for evaluation. In one targeted community, free copies of MSAGR were made available to PCPs, and data on emergency room visits and hospitalization of asthmatic patients were analyzed. Of the PCPs, 16% correctly classified mild, intermittent asthma, 13% mild, persistent asthma, 8% moderate, persistent asthma, and 8% severe, persistent asthma based on the combined patient's symptoms, PEFR or FEV1 value and PEFR variability as defined in National Asthma Education and Prevention Program guidelines. One hundred percent of the PCPs chose inhaled beta2-agonists as quick relief medication. Fifty percent of the PCPs chose inhaled steroids, leukotriene antagonists, oral theophylline, and long acting beta-agonists in various combinations for different severity of asthma. Eighty percent of the physicians failed to select the appropriate dosages of inhaled steroids for different severities of asthma. Ninety-five percent of PCPs reported that MSAGR made using the guidelines easier for them. In the targeted community, asthma-related emergency room visits decreased 22.5% and hospitalizations by 26.9%. This is the first study that identified the reasons for poor adherence to asthma guidelines by PCPs, and introduced MSAGR as a practical "low-tech" tool to promote better adherence to asthma guidelines. MSAGR presents patient-specific recommendations, based on asthma guidelines in a user-friendly format that can save the physician time in real-world primary care settings, where such information is often needed instantly. The overwhelming majority of PCPs strongly agreed that MSAGR helped them recall the classification of asthma severity in a timely manner, to inquire about various triggers, and to use step therapy accurately and confidently. In one targeted community, MSAGR helped clinicians in primary care settings to achieve better asthma outcomes and to reduce both emergency room visits and hospitalizations.

Patterns and Predictors of Asthma-Related Emergency Department Use in Harlem

To assess the roles of poor access to care, psychological risk factors, and asthma severity in frequent emergency department (ED) use. A cross-sectional survey. Harlem Hospital Center ED and outpatient chest clinic. Three hundred seventy-five adult residents of Harlem, a predominantly African-American community in New York City. Asthma severity was assessed by self-reported symptoms using National Asthma Education and Prevention Program guidelines, health-care utilization, and psychometric scales. Respondents with more severe asthma were more likely to have a primary asthma care provider, and to have had more scheduled office visits for asthma in the year prior to the interview (mean number of visits for patients with severe asthma, 3.6 visits; moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Despite having a regular source of care, 69% of respondents identified the ED as their preferred source of care; 82% visited the ED more than once in the year prior to interview (median, four visits). Persons with moderate or severe asthma were 3.8 times more likely to be frequent ED users compared to those with mild asthma (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2 to 6.6). This was the strongest predictor of frequent ED use. Other predictors of ED use were number of comorbid disorders (OR, 1.5; 95% CI, 1.1 to 2.1) and self-reported global health in the year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7). Psychological characteristics were not predictive of frequent ED use when controlling for disease severity. Frequent ED users present with serious medical conditions. They do not substitute physician care with ED care; they augment it to address serious health needs.

ASTHMA

Asthma is an important and increasingly prevalent respiratory disease. Its proper diagnosis and treatment lie at the heart of improving asthma outcome. Unfortunately, asthma has many faces and is affected by many variables, many of them difficult to control. Like many chronic illnesses, asthma tends to affect the poor and less advantaged individuals in society. Heightened awareness among patients and physicians of the serious nature of the disease is needed to reduce the morbidity and mortality of asthma. Treatment clearly requires a multifaceted approach, including behavioral, environmental, social, and medical interventions, in which the National Asthma Education and Prevention Program guidelines provide a logical, step-wise, and effective approach.

Consistency of care with national guidelines for children with asthma in managed care

Objective: To evaluate the consistency of pediatric asthma care with the National Asthma Education and Prevention Program Guidelines. Design: Cross-sectional survey at 2 managed care organizations in the United States (winter 1997-1998). The participants were parents of children (n = 318) age 5 to 17 years with asthma. There were no interventions. The outcome measures were indicators of care in 4 domains: (1) periodic physiologic assessment, (2) proper use of medications, (3) patient education, and (4) control of factors contributing to asthma severity. Results: Of 533 eligible patients with asthma, 318 (60%) parents responded; 59% of children were male, 76% were white, and 60% were aged 5 to 10 years. Deficiencies in care were identified in all care domains including, for patients with moderate and severe persistent symptoms, only 55% used long-term control medication daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing. Conclusions: There are significant opportunities to improve the quality of care for children with asthma enrolled in managed care. A comprehensive approach to improving care may be necessary to address multiple aspects of care where opportunities exist. (J Pediatr 2001;138:59-64)

Inaccuracy of “Personal Best” Peak Expiratory Flow Rate Reported by Inner-City Patients with Acute Asthma

Percent predicted peak expiratory flow (PEF) is used to determine the severity of asthma exacerbation and the appropriateness of discharge from the emergency department (ED). The 1995 Global Initiative for Asthma and 1997 National Asthma Education and Prevention Program guidelines recommend using a patient's “personal best” PEF, if available, as a better measurement than the predicted PEF obtained from population-based nomograms. We evaluated the accuracy of personal best PEF as provided by inner-city ED patients with acute asthma. One hundred four patients with acute asthma agreed to return to the ED for repeat PEF measurements on days 3, 7, 12, 21, and 24 after their initial ED visits for acute asthma. At the ED visit, only 29% (30/104) of patients were able to report a personal best PEF. Over the 24 days of follow-up, 45% (10/22) of these patients had a measured PEF greater than their reported personal best. If a predicted PEF of at least 70% was used as the criterion for ED discharge, as several asthma guidelines recommend, then using patients' reported personal best PEF would have led to inappropriate ED discharge for some patients.

Self-Reported Physician Practices for Children With Asthma: Are National Guidelines Followed?

To determine self-reported adherence to national asthma guidelines for children by primary care physicians in managed care; and, to analyze sources of variation in these practices by physician specialty and managed care practice type. A survey of 671 primary care physicians (pediatricians and family physicians) practicing in 3 geographically diverse managed care organizations (MCO). Domains of interest included asthma diagnosis, pharmacotherapy, patient education and follow-up, and indications for specialty referral. Item formats included self-reports of usual practice and responses to case vignettes. A total of 429 (64%) physicians returned surveys, 22 of whom did not meet criteria for inclusion in the analysis. Most respondents had both heard of (91%) and read (72%) the National Asthma Education and Prevention Program (NAEPP) guidelines. For diagnosis, 75% reported routine use of office peak flow measurement, but only 21% used spirometry routinely. Family physicians were more likely than pediatricians to use spirometry in diagnosis (odds ratio [OR] = 5.9), and less likely to recommend daily peak flow measurement (OR =.3). The median reported frequency of providing written care plans was only 50%. Though inhaled corticosteroids were deemed very safe or safe by 93%, almost half had specific concerns regarding at least 1 side effect, most commonly growth delay. Primary care physicians' criteria for referral to an asthma specialist differed from those of the NAEPP panel in choosing to manage more severe patients without asthma specialist input. Family physicians were more likely than pediatricians to refer a child after a single hospitalization, 2 to 3 emergency department visits, after 2 exacerbations, or if the child was <3 years old and required daily medications. Responses to vignettes showed generally appropriate initial use of antiinflammatory agents, but reluctance to increase the dose in response to continued symptoms, and less frequent follow-up than recommended by the NAEPP. Most physicians for children report having read and adopted NAEPP guideline recommendations for asthma treatment, including generally appropriate use of medications. Opportunities for improvement exist in specific areas such as the use of written care plans, optimizing antiinflammatory dosing, and providing routine follow-up. Although physicians show evidence of awareness of national guidelines and knowledge consistent with much of their content, additional work is required to promote the use of self-management tools in practice.

Combination of Inhaled Corticosteroids Plus Other Medications in the Management of Moderate to Severe Persistent Asthma

Severe persistent asthma accounts for a small percentage, probably less than 5% of all patients with asthma, but is responsible for the major portion of health care costs associated with the illness. According to the National Institutes of Health (National Asthma Education and Prevention Program) guidelines for the management of asthma, patients with severe asthma should be treated with high dosages of inhaled corticosteroids. These inhaled corticosteroids can be given in conjunction with a brief course of oral or parenteral systemic steroids, but it is best to decrease or eliminate systemic corticosteroid therapy whenever possible to prevent the side effects of long-term oral prednisone therapy. If inhaled corticosteroids do not control the asthma, then one or perhaps two, and even three, other long-term control medications can be added to the therapy regimen. Current guidelines recommend adding a long-acting beta 2-agonist such as salmeterol to the inhaled corticosteroid. Recent evidence suggests that leukotriene receptor antagonists can also be used in conjunction with inhaled steroids. Theophylline is also recommended as another controller agent to be considered. Unfortunately, no studies have comparatively evaluated all of these different classes of agents, even in moderate asthma, in head-to-head trials. This manuscript will review the current literature and provide the author's perspective on the combination of these medications in the pharmacologic management of moderate to severe persistent asthma.

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.

Prevalence of Cocaine Use and Its Impact on Asthma Exacerbation in an Urban Population

To assess the prevalence of cocaine use, and its impact on severity of presentation, among adults presenting to the emergency department (ED) with asthma. A secondary aim was to assess the use of various asthma treatment modalities, with reference to the 1997 National Asthma Education and Prevention Program (NAEPP) guidelines. All adults aged 18 to 55 years who presented to the ED of this institution with an asthma attack, were approached about participating in the study, which required giving informed consent, answering a facilitated questionnaire, and giving a urine sample for drug screening. Patients were enrolled during a 7-month period. A total of 163 patients were approached to enter the study; 116 patients consented to participate in the study, with 103 submitting complete urine samples. Thirty-seven patients refused to participate, and 10 were excluded. Sixty-eight percent of the patients were women, with a mean age of 33 years. African-Americans made up 89% of the total group. Thirty-five percent were cigarette smokers. Urine cocaine tests were positive in 13 of 103 (13%); 6 of 103 (5.8%) were positive for opiates. In the cocaine-positive group, 5 of 13 patients (38%) were admitted to the hospital, including two patients requiring intubation and mechanical ventilation. Of the total group, 23 of 103 patients (22%) were admitted, and 5 of those 23 admitted patients (22%) were cocaine-positive. Length of stay was significantly longer (5 vs 2.5 days, p < 0.05) in the cocaine-positive admitted patients. Forty-six percent of all patients reported using inhaled corticosteroids (ICS), with 39% of admitted patients using them. Thirty-two percent of all patients had obtained three or more refills of their beta(2)-agonist inhaler in the previous month. The prevalence of cocaine use may be much higher than the 13% shown in this study, because of patients' refusal to participate in the study. Second, the severity of exacerbation appears to be worse in the cocaine-positive group. Finally, the majority of patients presenting did not use ICS in accordance with the NAEPP guidelines.

Beliefs about diagnosing asthma in young children.

To determine what factors primary care pediatricians believe are important in establishing the initial diagnosis of childhood asthma and to identify variations in physicians' beliefs concerning this clinical decision. Massachusetts American Academy of Pediatrics Fellows were surveyed about their beliefs concerning the importance of 20 clinical factors associated with establishing the initial diagnosis of asthma. Most clinicians considered recurrent wheeze (96%), symptomatic improvement with a bronchodilator (90%), recurrent cough (89%), exclusion of alternative diagnoses (87%), and suggestive peak flow findings (82%) as important in diagnosing asthma. However, there was substantial heterogeneity among clinicians as to which combinations of factors they each considered relevant; for example, only 60% identified all 5 of the above factors to be necessary or important. Further, <50% identified presence of any of the 20 factors as necessary. Although national guidelines cite objective assessment of pulmonary function as essential, spirometry and peak expiratory flow testing were identified as necessary by only 8% and 10%, respectively. Two factors believed to contribute to establishing the asthma diagnosis contradicted the National Asthma Education and Prevention Program guidelines and expert opinion (age >2 years and absence of fever during episodes) and these beliefs were more likely held by those clinicians in practice for >5 years. The majority of pediatricians believe several common clinical factors establish a diagnosis of childhood asthma, but disagree over what combinations of these factors are important. Some misconceptions persist despite wide dissemination of clinical practice guidelines. We believe that future asthma guidelines will need to organize diagnostic criteria in an easily understood format, like a decision tree, to facilitate early recognition of asthma in young children.