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Selective Provision of Asthma Self-Management Tools to Families

^a Department of Pediatrics
^b Department of Epidemiology and Biostatistics
^c Institute for Health Policy Studies, University of California, San Francisco, California
^d Division of Allergy, Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan
^e Center for Managing Chronic Disease, University of Michigan, Ann Arbor, Michigan

	ABSTRACT

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OBJECTIVE. Providing asthma education in a primary care setting can be challenging because of time and resource constraints. The purpose of this work was to determine factors associated with the provision of different asthma self-management tools.

METHODS. We conducted a cross-sectional survey with 896 parents of children with asthma (age 2–12 years). We collected information regarding demographics and asthma care, including parent receipt of an asthma action plan, a symptom diary, and asthma information materials; whether an asthma management plan was sent to the child's school; and whether the physician reviewed written instructions on use of a metered-dose inhaler. We used multivariate logistic regression methods to determine factors associated with receipt of different asthma self-management tools controlling for demographic factors.

RESULTS. For families where parents only completed high school, there was greater likelihood of receipt of an asthma action plan and physician review of written instructions about how to use an inhaler. For families with a household income less than twice the poverty line, there was greater likelihood of receipt of an asthma action plan, the physician sending a letter to the child's school regarding the child's asthma, and receipt of an asthma symptom diary.

CONCLUSIONS. In our sample, primary care pediatricians do not routinely provide asthma education in accordance with National Heart, Lung, and Blood Institute asthma guidelines and "triage" which families receive additional asthma education. We believe that the use of targeted asthma education is a symptom of the limited time and competing demands during a typical visit. As a result, those involved in quality improvement need to help physicians become more efficient and effective at providing asthma education within such time constraints or develop alternative systems of providing asthma education.

Key Words: asthma action plan • asthma diary • physician practice patterns • physician guideline adherence

Abbreviations: NHLBI—National Heart, Lung, and Blood Institute • FPL—federal poverty line • OR—odds ratio • CI—confidence interval

Asthma affects >6 million children, of whom over half suffer from an asthma episode annually.¹ This toll disproportionately affects children from certain demographic groups defined by socioeconomic status, parent education level, ethnicity, and language.^2–4 To optimize asthma management, practice guidelines published by the National Heart, Lung, and Blood Institute (NHLBI) recommend that all patients receive asthma education. Establishing an ongoing partnership between physician and family is an essential component of the NHLBI guidelines.⁵ Without appropriate self-management and asthma education, physician recommendations are less likely to be effective.

Specifically, the guidelines recommend that all patients be given a written action plan that includes instructions for daily management with adjustment of medications in response to symptoms, as well as simple written materials that reinforce asthma management skills. For school-aged children, the guidelines recommend providing school personnel with a management plan to help manage the disease. For children who require daily monitoring of symptoms, the guidelines recommend use of a peak flow meter with a symptom diary.⁵

Many factors likely influence the provision of asthma education self-management tools in the primary care setting. The scope of services expected from primary care physicians is increasing,⁶ yet the amount of time for the typical office visit has not increased substantially.⁷ However, access to subspecialist care, asthma educators, community asthma coalitions, and increased primary care visits may improve the likelihood of receipt of asthma self-management tools.^8–10 We hypothesized that significant gaps exist between the current evidence-based guidelines and everyday primary care practice. In addition, current practice patterns may offer insight into the challenges that primary care providers face and reasons for disparities in current asthma care, as well as potential areas for quality improvement. The purpose of this study was to assess the frequency with which physicians provided specific asthma self-management tools and to assess which factors are associated with parent report of receipt of such tools.

	METHODS

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We conducted a secondary data analysis of baseline data from a completed, randomized, controlled trial for asthma in 10 regions of the United States. The institutional review board of the University of Michigan, as well as of other participating institutions, approved the study protocol. We have published previous analyses from this data set to describe environmental control actions taken by parents, parent perception of asthma symptoms, and comparisons of classifications of asthma severity using different measures.^11–13

Study Population
The 896 pediatric patients in the sample were a random sample of children with asthma from the patient panels of pediatricians participating in a randomized, controlled trial to evaluate the effect of physician asthma education. In the trial, physicians were randomly assigned to receive a 5-hour interactive seminar on proper asthma management and patient communication; however, data collection occurred before any of the physicians participated in the study intervention. The details of the study population, recruitment methods, and data collection are described elsewhere.¹⁴ The physician sample was a convenience sample of 8% of all of the potential primary care providers who were informed about the study at the study sites, which included the following: Corpus Christi, TX; Bakersfield, CA; Nashville, TN; Jacksonville, FL; Omaha, NE; St Paul, MN; Kent County, MI; New Castle County, DE; Columbus, OH; and Indianapolis, IN.

Criteria for inclusion in the study were as follows: a child must be between 2 and 12 years of age, have no diseases with associated pulmonary complications (such as tuberculosis, sickle cell disease, or cystic fibrosis), and have active asthma (1 hospitalization, emergency department visit, or emergent visit for asthma over the past 2 years). Between July 2001 and June 2002, we completed interviews with the parents of 896 of these 1077 potentially eligible patients, for a response rate of 83%.

Data Collection and Survey Instrument
After obtaining consent from the child's parent or legal guardian, we conducted the interview with the person who "is usually responsible for [child]'s health-related care and takes him/her to the doctor." The 86-item interview was conducted in English and took 25 minutes to complete. Respondents received an honorarium of $10. As described previously,¹⁴ we collected information regarding demographics, asthma symptoms and severity, health care use, and parent-reported receipt of asthma self-management tools.

Definition of Variables
The following variables and definitions were used in this analysis. Poverty was defined as income above or below the 2004 federal poverty line (FPL) adjusted for the number of people dependant on the income. We created the following 6 categories: income less than the FPL, income greater or equal to the FPL and <2 times the FPL, income greater or equal to twice the FPL and <3 times the FPL, and so forth, until a category of income >5 times the FPL. Parent race (white or nonwhite) was self-reported.

We also asked parents about the number of emergency department visits, hospitalizations, and urgent office visits for asthma made in the last 12 months. We also asked if the patient was under the care of a subspecialist for asthma. To determine asthma medications, we asked parents to list the specific name of any asthma medications the child was taking, the frequency of use, the mode of delivery, and whether the medication was used with a spacer.

Respondent education was the self-reported highest level of education completed. This item was collapsed into high school graduate or less, some college or trade school, and college graduate or more. Respondent smoking status was also self-reported. Persistent asthma was defined based on parent report of the child having night time symptoms >2 times per month or daytime symptoms >2 times per week.

For our outcome of interest, we asked about parent-reported receipt of the following asthma self-management tools: an asthma action plan, an asthma symptom diary, an asthma management plan sent to the child's school (if the child attends a school), and generic asthma information materials. We included this cross-section of different asthma management tools because it represents materials that are used at different settings (eg, physician's office, home, or school).

An action plan was defined as any individualized written material from the provider that included information that identified which asthma medication to take, the amount of such medicine, and the specific circumstances in which to take the medication. Because the NHLBI guidelines recommend that all patients with asthma be prescribed a quick-relief β-agonist, we also asked if the physician reviewed written instructions on how to use a metered-dose inhaler.

Analyses
We conducted 5 separate analyses for 5 different outcomes of interest listed above and determined the percentages of parents that received each of the appropriate actions. We used logistic regression to analyze the separate associations among the following independent variables: child age, gender, asthma severity, parental smoking status, parental education level, subspecialist care for asthma, and household income in relation to the poverty level with the receipt of 1 of the 5 self-management tools. On inspection of the data, we noted that the likelihood of receipt of an asthma self-management tool was highest at the lowest level of income (less than FPL); however, because of the small number of families at this level (n = 46), we collapsed the household income variable by using a cutoff of 2 times the FPL (n = 155).

We used multivariate logistic regression to model the possible relationship between receipt of the asthma education method and the same independent variables. We used generalized estimating equations (linear and logistic) to account for the fact that patients were clustered by physicians and the data from different patients seen by the same physician may be correlated.

We used the Kruskal-Wallis method to test the association between parent demographic characteristics (parent education level and household income) and asthma health care use (emergency department visits and hospitalizations). Statistical significance was defined as P value of <.05. All of the statistics were calculated by using SAS 9.1 (SAS Institute, Inc, Cary, NC).

	RESULTS

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Respondents
Patient demographics are presented in Table 1. Patients had a mean age of 7 years (range: 2–12 years). Sixty-five percent were boys. Seventy-two percent of parents were white; 12% were black. Thirty-seven percent were categorized as persistent by evaluation of symptoms per the questionnaire. Ninety-three percent of the caregivers identified themselves as the mother, 13% were current smokers, and 75% had more than a high school education.

Use of Inhalers and Spacers
The NHLBI guidelines recommend that all patients with asthma have a β-agonist medication available to relieve symptoms. The most common delivery device is a metered-dose inhaler, which the NHLBI guidelines recommend be used with a spacer device. We asked parents about current medications and received complete responses from 883 parents.

We found that 704 (80%) of 883 parents reported that their child currently had an inhaler. Of the 704 patients with an inhaler at home, 318 (45%) were prescribed both an inhaled β-agonist and an inhaled controller medication, 193 (27%) were prescribed only an inhaled β-agonist, 134 (19%) reported being prescribed only an inhaled controller medication, and 59 (8%) of caregivers were not able to identify the type of medication in the inhaler. Although an inhaler is more effective with a spacer device, only 559 (79%) of the 704 parents reported that their child had an inhaler and a spacer. We also noted that 396 (56%) of 704 caregivers reported that their physician had reviewed written instructions on how to use an inhaler.

Multivariate Analysis
We hypothesized that certain patient characteristics may be associated with physician adherence to guideline-recommended practices related to the provision of self-management tools. Table 2 shows the results of multivariate logistic regression analysis of the likelihood of receipt of each of the different types of asthma tools, controlling for patient characteristics.

	DISCUSSION

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In our sample, we found that primary care pediatricians do not routinely provide asthma self-management support to all of their patients in accordance with the NHLBI asthma guidelines. Our results suggest that pediatricians are selective or "triage" which families receive asthma education, because those children whose parents have completed less formal education or those children who are from households with a lower income level are more likely to receive additional asthma instruction and educational materials.

Incorporation of appropriate asthma education tools in primary care remains a challenge. Our study is similar to several studies that have documented that many patients do not receive proper preventive asthma care. For example, in our study, we found that only 36% had received an asthma action plan. In a population most similar to our study of children recruited from several pediatric practices affiliated with urban hospitals, the frequency of receipt of an asthma action plan was 39%.¹⁵ Other studies have reported rates of 28% for children enrolled in Medicaid managed care to a rate of 43% for children in private practices presenting for an emergency department visit.^16,17

The overall observation that most physicians do not adhere to all of the educational recommendations of the NHLBI guidelines is not surprising; however, we found that certain parent and household characteristics were associated with physician use of asthma education recommendations. Specifically, those children whose parents have completed less formal education or those children who are from households with a lower income level and those with higher levels of health care use were more likely to receive additional asthma self-management tools in the form of action plans, written instructions, asthma diaries, and letters for the child's school from their primary care provider.

The NHLBI guidelines recommend that asthma care should include education, with tailored management plans for all families, not withstanding the need to pay particular attention to the most vulnerable.⁵ Although certain demographics are associated with less favorable asthma outcomes in subgroups of the population, on an individual basis, it is difficult to predict which specific patients will do well in the treatment plan. Physicians have been shown to be inaccurate when predicting which parents will adhere or not to their therapeutic^18,19 or environmental modification recommendations.¹¹ Eventual asthma self-management is not consistently associated with specific patient characteristics.²⁰ Any family, despite the level of affluence or education, can be expected to benefit from having asthma self-management tools and receiving asthma education.

The failure of primary care physicians to provide consistent asthma education may be symptomatic of the limited time to conduct all of the necessary tasks in a limited primary care visit. However, perceived time constraints may not be the barrier some suggest. Evaluations of successful interventions that teach physicians specific communication techniques to improve asthma self-management have shown that additional time is not required to combine effective treatment and education.¹⁴ Other potential strategies include referral to case management or community asthma coalitions.^21,22 These strategies may have the potential advantage of addressing other barriers to optimal asthma care by harnessing community resources.¹⁰ Another barrier to providing asthma education to all patients in the office is the perceived lack of reimbursement from third-party payers.²³ Instruction regarding proper documentation, coding, and reimbursement for asthma education may also be an important component for encouraging clinicians to provide asthma education on a consistent basis.¹⁴

We noted that primary care providers are selective in providing asthma self-management tools to certain subpopulations. This observation may be because pediatricians may be targeting for guidance those children from families who they believe are most at risk of asthma morbidity. For example, when we compared asthma health care use based on parent education level and household income (Table 3), we observed that lower parent education level and lower household income was associated with increased asthma health care use.

The education that accompanies the self-management tool may be the important factor in the success of the tool, and we did not have additional information on the quality or intensity of the education that occurred when the materials were distributed. As a result, we did not attempt to value 1 type of asthma education material (eg, asthma action plans or asthma symptom diaries) over another.

Previous studies suggest that access to subspecialist care and asthma educators may improve the likelihood of receipt of asthma self-management tools.^8,9 In our analysis, when we controlled for subspecialist care, there was no effect in the likelihood of receipt of asthma educational materials. However, we were not able to control for access to other sources of additional care, such as community asthma educators or counselors. In addition, the baseline data are from patients of physicians participating in a trial of a physician education intervention. The practice patterns of these physicians may not be generalizable to all pediatricians.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We found that primary care pediatricians do not routinely provide asthma education in accordance with the NHLBI asthma guidelines and are selective or triage which families receive additional asthma education. We believe that the use of targeted asthma education is a symptom of the limited time and competing demands during a typical patient visit. As a result, those involved in quality improvement need to help physicians become more efficient and effective at providing asthma education within such time constraints or develop alternative systems of providing asthma education. In addition, the seamless referral of children with more severe asthma to a subspecialist may help improve access to guideline-recommended education, because specialty visits may allow time for asthma education. Physicians should also be aware of resources in their community that provide asthma education.

At a policy level, evidence-based reimbursement may be just as critical as the practice of evidence-based medicine. Those involved in health policy should examine methods of primary care reimbursement to ensure that reimbursement incentives are aligned with proven methods to improve asthma outcomes, such as provision of asthma self-management tools and education. Such forms of patient care must reach all children with asthma and, at the same time, provide the additional needed support to those most vulnerable to poor asthma outcomes.

	ACKNOWLEDGMENTS

 
This work was funded by the Robert Wood Johnson Foundation (Princeton, NJ) and the National Institutes of Health (grant HL070771).

	FOOTNOTES

 
Accepted Sep 20, 2007.

Address correspondence to Michael D. Cabana, MD, MPH, Division of General Pediatrics, University of California, San Francisco, 3333 California St, Laurel Heights Building #245, San Francisco, CA 94118. E-mail: michael.cabana{at}ucsf.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

What's Known On This Subject Primary care pediatrician adherence to National Heart, Lung, and Blood Institute asthma guidelines is poor.

 

What This Study Adds We noted that primary care pediatricians triage which families (eg, lower income and lower education) receive additional asthma education. This is a symptom of the limited time and competing demands during a typical visit.

 

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Google Scholar Articles by Cabana, M. D. Articles by Clark, N. M. PubMed PubMed Citation Articles by Cabana, M. D. Articles by Clark, N. M. Related Collections Asthma

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