Halterman JS, Yoos L, Kaczorowski JM, et al. Arch Pediatr Adolesc Med. 2002;156:141–146
Purpose of the Study.
To evaluate the use of preventative asthma medications in an urban population of children with mild persistent to severe persistent asthma and to evaluate the accuracy of classification of asthma severity by health care providers.
Children 4 to 6 years old from 33 urban schools in Rochester, New York, enrolled in a longitudinal clinical trial. Asthmatic children were identified through a school-based health screening survey. Of 322 asthmatic children, 92 (67%) were enrolled.
Telephone survey reviewing sociodemographic characteristics, health care contacts, and medication use. A written questionnaire was sent to health care providers to evaluate each child’s health care utilization, asthma severity, and medication use. Information was based on personal knowledge and review of the medical record. Provider response rate was 98%. Eligibility was based on an asthma severity rating of mild persistent or worse. Symptom criteria were derived from the National Heart, Lung, and Blood Institute (NHLBI) guidelines (1997), which included: 1) days with asthma symptoms and 2) nights with asthma symptoms. Statistical analysis was performed using standard cross-tabulations and χ2 analyses. Logistic regression was used for multivariate analysis.
Seventy percent of patients had ≥3 days/week with asthma symptoms and 68% had ≥3 nights/month with asthma symptoms. Patient characteristics: 4 years, 27%; 5 years, 38%; 6 years, 35%; male, 64%; white, 8%; black, 67%; other, 25%; Hispanic, 30%; and Medicaid, 73%. Fifty percent of patients were prescribed maintenance medication, 41% actually had the maintenance medication, and 36% used maintenance medication. Comparing accurately to inaccurately classified patients 83% versus 28% were prescribed maintenance medicines (meds), 64% versus 26% had maintenance meds, and 58% versus 20% used maintenance meds. Patients observed in the office within past 6 months were more likely to be accurately classified (47% vs 25%). If the family reported that they believed the provider was aware versus unaware of asthma severity, the classification was more likely to be accurate (46% vs 20%).
This study reveals that inaccurate classification of asthma severity by providers, as well patient compliance with medications regimens, is a significant impediment to optimal asthma management. When patients were appropriately classified, maintenance medications were commonly prescribed. Incomplete communication between patient’s families and providers is believed to contribute to inaccuracy of classification.
This report provides information useful to health care providers regarding potential impediments to optimal management of asthma, which has increased both in incidence and severity in recent decades and is a significant source of morbidity and mortality. A limitation of this study was acceptance of caretaker description of asthma symptoms as the gold standard of symptom severity. Depending on caretaker knowledge, these assessments can be difficult to obtain by telephone in a limited period of time. In addition, the screening criteria for eligibility in the study (days/nights with asthma symptoms) were limited and may have resulted in an over- or underestimation of asthma severity. Importantly, of the total number of children with asthma, only 67% (92) of parents responded to the survey. This relatively low number may introduce a selection bias into the results. Indeed, this study does represent a narrow sample of patients, 4 to 6 years of age and urban. Therefore, this study may not be broadly generalizable. This report does demonstrate, however, that both inaccuracies in asthma severity classification on the part of health care providers as well as patient compliance can negatively affect asthma management. Perhaps patient questionnaires regarding asthma symptoms so that asthma severity can be classified during the visits as well as patient asthma education by trained personnel, and referral for difficult to control asthma symptoms may lead to improved adherence to optimal maintenance medication.