Wolfenden LL, Diette GB, Krishnan JA, Skinner EA, Steinwachs DM, Wu AW. Arch Intern Med. 2003;163:231–236
Purpose of the Study.
To determine how physician estimates of patients’ underlying asthma severity affect asthma care.
A total of 4005 adult asthma patients enrolled in managed care organizations and the physicians who were primarily responsible for their asthma care were studied.
Patient- and physician-reported data were used to examine the relationship between physician estimates of underlying asthma severity and asthma care. Asthma patients were asked about asthma symptoms and asthma medical care. Asthma care questions included questions regarding medication use, self-monitoring, self-management, and allergy history and treatment. The physicians were instructed to evaluate the severity of their patients’ asthma, and 4005 patients had complete physician estimates of underlying severity. Relationships between physician severity classifications, patient-reported symptoms, and asthma care were examined, and multivariate logistic regression analyses were used to adjust for age, gender, race, and education.
The mean age of the respondents was 44.8 years; 83.5% were white and 70.1% were female. Almost 40% of respondents reported moderate symptoms and 50.1% reported severe symptoms, but 44.6% of physicians classified their patients’ underlying asthma severity as mild and 44.5% as moderate. After adjustment for patient-reported symptoms, the odds of receiving each component of asthma care were greater when the physician estimate of severity was moderate (odds ratio: 1.92; 95% confidence interval: 1.65–2.22) or severe (odds ratio: 4.97; 95% confidence interval: 3.58–6.89) than when the physician estimate was mild. The more severe the patient-reported symptoms, the more likely patients were to receive inhaled corticosteroids and peak flow meters but the less likely they were to have self-management knowledge, even after adjustment for physician estimates of severity. Physician-estimated severity was a stronger predictor of asthma care than were patient-reported symptoms.
In a population of adult asthmatic patients, physician estimates of asthma severity determined the asthma care reported by patients but physicians might underestimate asthma severity, resulting in suboptimal care.
These results suggested that physician underestimation of asthma severity may lead to the delivery of asthma care that is not consistent with national guidelines. Because the participants were predominantly white female adults, these results may not be applicable to other populations. In addition, physician estimates of underlying severity were obtained 1 to 6 months after patients reported symptoms, resulting in a time lag that might explain at least some of the discrepancy between patient-reported symptoms and physician estimates of underlying severity. Studies of pediatric asthmatic patients are needed, to determine the prevalence of physician underestimation of asthma severity and its effects on asthma care and ultimately on asthma outcomes.