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From the Department of Immunology/Microbiology (Dr. Grant), the Center for Health Services Research, Rush Primary Care Institute (Ms. Turner-Roan, Drs. Daugherty, and Weiss), Rush-Presbyterian-St. Luke's Medical Center, and the Department of Pediatrics, Cook County Children's Hospital (Dr. Moy), Chicago, IL.
See Appendix for other members of the CASI Project Team.
Correspondence to: Kevin B. Weiss, MD, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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Methods: In 1997, a self-administered survey was mailed to a randomly selected 10% sample of Chicago-area general pediatricians, internists, and family practitioners.
Results: Surveys were returned by 244 of the 405
eligible Chicago-area primary-care physicians (60.2%) in the sample.
Of these, 66 (27.6%) were pediatricians, 83 (34.7%) were general
internists, and 90 (37.7%) were family practitioners. Physicians
reported that 54.6 ± 2.7% (mean ± SE) of patients with
newly diagnosed asthma have spirometry performed as part of their
initial evaluation. For patients with moderate persistent
asthma,prescribing of inhaled corticosteroids varied by patient
age, with 60.5% of physicians routinely prescribing them for patients
< 5 years, compared with 95.7% of physicians prescribing them for
patients 
5 years. Awareness of the NAEPP guide-lines among
these physicians was high, with 88.5% reporting that they have heard
of the guidelines, and 73.6% reporting having read them. Of patients
with moderate or severe persistent asthma, physicians estimated that
47.7 ± 2.7% were given written treatment plans.
Conclusion: Several aspects of the NAEPP guidelines appear to have been incorporated into clinical practice by Chicago-area primary-care physicians, whereas other recommendations do not appear to have been readily adopted. This information suggests areas for interventions to improve primary care for asthma in the Chicago area.
(CHEST 1999; 116:145S–154S
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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Because primary-care physicians provide approximately two thirds of all ambulatory asthma care in the United States,8 the primary-care community was the target of a large publicity effort to increase awareness of these guidelines. Subsequently, studies of several aspects of asthma care, in particular, emergency asthma care for children9 and inhaled corticosteroid prescription dispensing rates,10 11 have suggested the presence of a gap between actual care and the recommendations of the NAEPP.
Although primary-care physicians were the target audience of the NAEPP expert panel, there is little published information describing primary-care physicians' willingness to embrace the guidelines. This study examines the asthma care practices of Chicago-area primary-care physicians and assesses these practition-ers' current thoughts about several aspects of the NAEPP guidelines.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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Survey Instrument
A self-administered instrument was constructed on the basis of
surveys developed by the National Heart, Lung, and Blood
Institute,12
the Quality Assurance Reform Initiative
project of the National Committee on Quality
Assurance,13
and the Managed Health Care
Association.14
The survey addressed (1) asthma diagnosis;
(2) clinical monitoring of asthma patients; (3) pharmacologic treatment
of asthma patients; (4) nonpharmacologic treatment of asthma patients;
(5) opinions and beliefs about asthma treatment options; (6)
involvement in continuing medical education activities related to
asthma; (7) use of asthma practice guidelines; and (8) demographic
information about the respondents and their practice settings. Because
the data collection timeline overlapped with the distribution of the
revised NAEPP guidelines (released in 1997),15
the survey
items were chosen to reflect content of both the original and the
revised versions of the guidelines whenever possible. Revisions were
made to this original survey on the basis of comments from an advisory
group of primary-care and specialty physicians. The final survey
consisted of 134 items. To reduce the burden for the respondent, the
survey was divided between two versions, A and B, with 45 shared items,
including 35 demographic items. The A and B versions contained 91 and
88 items, respectively.
Because some elements of asthma care vary by patient age, the wording
of some of the questions was modified to make the items appropriate for
the age groups seen by each primary-care specialty. For questions
pertaining to pharmacotherapy, pediatricians were asked to respond
separately for patients < 5 years of age and those 5 years of
age. Similarly, family medicine practitioners were asked to respond
separately for children < 5 years, 5 through 15 years, and 16
years of age. For some items, the question or response choices included
the term "routinely"; the precise meaning of this term was not
defined, requiring the respondent's interpretation.
This project was approved by the Institutional Review Board of Rush-Presbyterian-St. Luke's Medical Center.
Study Population
Chicago-area primary-care physicians (general pediatricians,
general internists, family medicine practitioners, and general
practitioners) in clinical practice were identified from the American
Medical Association (AMA) 1995 Masterfile.16
This
Masterfile contains names and professional information on all
physicians in the United States who have completed or are in the
process of completing requirements to practice medicine.
Physicians meeting the following criteria were identified: (1) primary self-designated practice specialty of pediatrics, internal medicine, family practice, or general practice; (2) practice location in Cook, Lake, Du Page, McHenry, Kane, or Will counties, IL; and (3) engaged in direct patient care.
Sampling Methods
The AMA Masterfile contained listings for 3,804 primary-care
physicians that matched the study criteria. These included 882
pediatricians, 1,598 internists, 1,021 family practitioners, and 303
general practitioners. In anticipation of possible inaccuracies in the
AMA Masterfile, an approximately 12% random sample of physicians from
each specialty was chosen to achieve a final sample of approximately
10%.
In 1997, surveys were mailed to physicians along with an accompanying cover letter, and a postage-paid return envelope. Physicians were requested to return the surveys by either mail or fax. To maximize the response rate, the first mailing was supplemented by additional mailings and telephone calls. A nominal incentive was offered to the physicians for completion of this survey.
Physicians were considered ineligible if they had retired, were deceased, or had moved their practice outside of the six-county study area. This information was obtained when the survey was returned, or, in the case of nonrespondents, through follow-up telephone calls. Of the sample of physicians initially surveyed, a higher-than-expected proportion (26.4%) was found to be ineligible. Therefore, a small supplemental random sample of physicians was chosen from the Masterfile to replace ineligible physicians. In total, surveys were mailed to 554 physicians, of whom 405 were eligible, representing a 10.6% sample of Chicago-area primary-care physicians.
Data Analysis
Completed surveys were excluded from this analysis if the
respondent reported that asthma patients constitute < 1% of his or
her practice. Data analysis was conducted using SAS software (SAS
Institute; Cary, NC) to calculate frequency distributions. Where
appropriate, tests of significance were performed using
2 or nonparametric analysis of variance. Means
are reported with the SE.
Results reported for family practitioners include physicians with either family practice or general practice as their self-designated practice specialty. For the purposes of this discussion, the term "very few" is used to describe responses reported by < 20% of the respondents, "minority" refers to 20 to 49%, "majority" refers to 50 to 79%, and "nearly all" refers to 80 to 100%.
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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General Characteristics of Physicians and Practices
The demographic characteristics of the responding physicians and
those of the other primary-care physicians in the 1995 AMA Masterfile
are displayed in Table 1
. The respondents were similar to the other Chicago-area physicians in
their primary specialties and major professional activities—37.7%
family practitioners, 27.6% pediatricians, and 34.7% internal
medicine. Ninety-four percent were office-based, and 5.9% were
hospital-based. The respondents differed significantly from the other
Chicago-area physicians in sex (45.2% vs 35.0% female; p < 0.01)
and medical education (69.9% vs 58.2% US graduates; p < 0.01). In
two other demographic features, age and years since medical school
graduation, respondents and the AMA Masterfile physicians had
differences that achieved statistical significance, but are of probable
minimal clinical relevance. The average age of the respondents was
45.1 ± 0.6 years, and their median number of years since medical
school graduation was 18.1.
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18 years. Nearly all family medicine practitioners
reported providing care for individuals of all age groups from 0
through 65 years and older. The most commonly reported practice type
was partnership or group practice (54.5%), with only 8.2% of
respondents a part of staff model health maintenance organizations. The
distribution of insurance status was diverse. On average, private
capitated patients (29.1 ±1.7%) and private fee-for-service
patients (28.3 ± 1.5%) represent the largest share of physician
practices. Fee-for-service Medicaid (13.5 ± 1.3%), Medicare
(13.8 ± 1.0%), and self-pay (7.9 ± 0.7%) were represented less
frequently. The respondents estimated that patients with asthma
represented an average of 9.0 ± 0.5% of their practice.
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Most physicians did not have direct access to spirometry; only 30.3% reported having a spirometer in their office. Yet "No access to spirometry" was reported rarely (1.3%). The most common description of access to spirometry was "off-site (another hospital or clinic)," reported by 53.9% of physicians. An additional 14.5% reported referring patients to a specialist for spirometry. Although only 20.1% of physicians described using either PEFR or spirometry "often" for asymptomatic patients, 53.6% of physicians used them "often" for acutely symptomatic patients.
Physicians were asked their opinions about the usefulness of home peak
flow monitoring. For patients ( 5 years) with moderate-to-severe
persistent asthma, 57.8% of physicians described routine home peak
flow monitoring as "often" useful, and 35.3% reported it to be
"somewhat" useful. Only 6.8% of physicians described home peak
flow monitoring as "rarely" or "never" useful.
Medications Used in Treating Patients With Asthma
Tables 4
and
5 display primary-care physicians' approaches to asthma
pharmacotherapy. The physicians reported that, in their practices, an
average of 90.0 ± 1.8% of patients with asthma are prescribed some
type of metered-dose inhaler; of these, 55.0 ± 2.6% are prescribed
a spacer device. Fewer patients with moderate or severe asthma were
estimated to have a corticosteroid inhaler prescribed
(81.9 ± 2.2%), and a larger proportion of these (63.7 ± 2.9%)
were reported to have spacer devices prescribed.
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5 years.
For patients 5 years, inhaled ß2-agonists
were the most frequently prescribed medication (reported by 96.4% of
physicians). Physicians reported oral
ß2-agonists were prescribed less frequently for
this age group than for patients < 5 years (25.5% vs 80.8%;
p = 0.001). Prescribing of inhaled corticosteroids was reported more
often for patients 5 years than for those < 5 years (95.7% vs
60.5%; p = 0.001). Although reported prescribing of cromolyn or
nedocromil appeared to be more frequent for the younger age group, this
difference did not achieve statistical significance (71.6% vs 58.8%;
p = 0.07). Theophylline, although not commonly prescribed, was more
likely to be given to patients 5 years than to those < 5 years
(24.3% vs 11.5%; p = 0.02).
The survey also included the following hypothetical clinical scenario:
"For a patient with daily symptoms that respond to three times a day
short-acting ß2-agonists as his or her only
medication, who is waking up more than twice a week with asthma
symptoms, what would you prescribe next?" This scenario was included
to better understand physicians' approaches to pharmacotherapy
independent from their knowledge of the NAEPP terminology for asthma
severity classification. Anti-inflammatory medications were the most
common response, with some differences seen between responses given for
children (ages 5 to 15 years) and adults ( 16 years). Among
internists and family practitioners responding to the adult patient
scenario, 63.5% responded that they would add corticosteroids. The
addition of cromolyn or nedocromil was the next-likely step, reported
by 17.3% of the respondents. Only 19.2% of the respondents did not
choose an inhaled anti-inflammatory medication in response to the
scenario. Among pediatricians and family practitioners responding to
the pediatric scenario, inhaled corticosteroids were selected somewhat
less frequently (40.4%), with a similar proportion choosing the
addition of cromolyn or nedocromil as the next step. Only 19.4% of
pediatricians and family practitioners did not choose to add any
anti-inflammatory medications as the next step.
The survey also queried physicians about their opinions on the safety
of prescribing inhaled corticosteroids at standard approved doses. As
seen in Figure 1
, 52.6% of the respondents perceived inhaled corticosteroids to be
"very safe" for patients > 5 years, whereas only 21.1% perceived
them to be "very safe" for children 
5 years
(p = 0.001).
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The survey included questions on aspects of asthma care such as standard procedures for scheduling asthma visits and providing patients with written treatment plans. The ability for patients to schedule same-day appointments for acute but not life-threatening exacerbations was reported by 78.2% of physicians. Referring these patients to the emergency department was reported less frequently (16.7%).
Physicians reported that they develop written treatment plans for an average of 47.7 ± 2.7% of their patients with moderate or severe persistent asthma. When asked to describe their approach to follow-up care for patients with moderate persistent asthma under good control, the majority of physicians reported scheduling regular follow-up visits. However, 19.7% of the physicians reported seeing patients only when they are symptomatic.
The survey also included several items about experiences related to managed care. When asked whether they had been contacted by a managed care organization or pharmaceutical benefits manager about prescribing patterns for patients with asthma, 27.0% of the physicians responded "yes." Nine percent reported encountering barriers from a managed care organization in trying to refer patients to an asthma specialist when they thought it was indicated.
Physicians reported participating in a variety of forms of professional education related to the management of asthma (Fig 2 ). Most commonly reported were the receipt of written materials or guidelines (87.2% of physicians) and attendance at continuing medical education seminars (79.0% of physicians). Participation in asthma-related peer review activities (15.5%) and patient care audits (11.4%) were less common.
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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Consistent with these findings, the results suggest that there are several key aspects in the delivery of asthma care by primary-care physicians that are consistent with the NAEPP guideline recommendations. For example, both the original and the revised NAEPP guidelines recommend the use of PEFR monitoring as an objective assessment of airway obstruction. The survey queried several aspects of peak flow use. Among the Chicago-area primary-care physicians surveyed, PEFR monitoring during office visits appears to be widespread, particularly for the evaluation of acutely symptomatic patients. The physicians appeared to use PEFR somewhat less often for routine monitoring of asymptomatic patients. The guidelines also recommend a brief trial of daily PEFR monitoring as an aid to establishing a diagnosis. However, in contrast to its prevailing use as an office procedure, only a minority of the surveyed physicians supported ambulatory PEFR monitoring as part of regular care for their patients with asthma.
In the area of pharmacotherapy, both the original and revised NAEPP guidelines recommend anti-inflammatory therapy for all patients with persistent asthma. However, previous studies have suggested that this recommendation has not been widely followed by physicians10 16 17 and has possibly contributed to increased morbidity for persons with asthma.18 In contrast to these other studies, this survey of Chicago-area primary-care physicians demonstrates high rates of inhaled anti-inflammatory prescriptions (according to self-report) when physicians were asked to identify medications they were likely to prescribe for "a patient with moderate persistent symptoms." However, when presented with a case describing symptoms of a patient with moderate to severe persistent asthma, fewer physicians chose addition of inhaled corticosteroids as the next step in treatment. The reasons for this discrepancy are unknown; one possibility is that it reflects physicians' uncertainty in classifying asthma severity. Although it is very possible that there is a gap between self-reported and actual practice of prescribing anti-inflammatory medications, the findings suggest that primary-care physicians in the Chicago area are, at a minimum, aware that anti-inflammatory therapy is the mainstay of treatment for patients with moderate persistent asthma.
In this survey, reported pharmacologic treatment for moderate persistent asthma varied significantly by patient age, with younger children less likely to be given prescriptions for inhaled ß2-agonists and inhaled corticosteroids, and more likely to receive oral ß2-agonists and inhaled cromolyn or nedocromil. Although expert opinion19 20 has suggested that, for all ages, the inhaled route for ß2-agonists is preferred to oral because of quicker onset of action and less systemic effect, > 80% of Chicago-area primary-care physicians who see children in their practice reported prescribing oral ß2-agonists for children < 5 years. This may reflect uncertainty as to how to effectively deliver inhaled medications to younger children.
The revised NAEPP guidelines recommend low- or medium-dose inhaled corticosteroids as the treatment of choice for children < 5 years with moderate persistent asthma. The differences in prescription of inhaled corticosteroids by patient age noted in the survey results may reflect less confidence in the safety of inhaled corticosteroids for younger children (< 5 years). These data suggest that studies demonstrating inhaled corticosteroid safety for young children as well as educational programs for physicians may be important ways to inform about an age effect in treatment choices.
The survey identified several other aspects of asthma care that were less consistent with the guideline recommendations. For example, both the original and the revised NAEPP guidelines recommend spirometry as a diagnostic test for all patients at initial presentation, but this does not appear to be the common practice of Chicago-area primary-care physicians. Further, the majority of Chicago-area physicians did not report having a spirometer in their office. These findings are consistent with a previous (1985) national study showing low rates of spirometry use among primary-care physicians.12 The survey data on spirometry highlights an important area for intervention. Improving access to spirometry in physicians' offices may increase the appropriate use of this test. However, there may also be barriers to office spirometry, including cost of the equipment, negative opinions about the usefulness of this test, and a reluctance to learn spirometry performance and interpretation.
Patient education is also an essential component of asthma care. Both the original NAEPP guidelines and the revised guidelines define key components and essential messages that should be delivered in office-based patient education. The revised guidelines suggest that in addition to education delivered by the clinician, all patients may benefit from formal asthma education programs taught by asthma educators. The survey results showed primary-care physicians made limited use of formal asthma education programs. This may be related to limited availability or awareness of these programs. Alternatively, this finding may reflect physicians' beliefs that the primary patient teaching responsibility lies with the clinician.
Both the original and the revised NAEPP guidelines also contain criteria for physician referral to an asthma specialist. Although the guidelines recommend referral for patients with a history of a life-threatening exacerbation, only 69% of the respondents in this survey reported initiating consultations with an asthma specialist for a history of a life-threatening event.
The use of written asthma treatment plans is a key aspect of patient education, and their use has been associated with decreased morbidity.21 However, the survey results indicate that many primary-care physicians in the Chicago area do not commonly give their patients written treatment plans. Perhaps there is a lack of awareness of this aspect of the guidelines, or uncertainty about the components of these treatment plans. The time constraints imposed by busy office schedules are another plausible explanation for not creating written treatment plans.
Finally, the survey results also showed a notable disparity in follow-up care. The guidelines recommend regularly scheduled office visits. Although the majority of respondents scheduled regular follow-up visits for asthma patients, nearly one in five reported seeing patients only when symptomatic.
Several limitations of this study should be noted. First, as with many surveys, little information about the nonrespondents is available, and the survey respondents may include a small overrepresentation of women and U.S. graduates. Second, as with any self-reported data, respondents may have reported what they believe to be acceptable, instead of their actual practice. Third, the findings reflect asthma care at a single point in time. The survey was conducted in 1997, overlapping with the distribution of the revised NAEPP guidelines. This makes it difficult to distinguish the relationship between the physicians' responses and the original or the revised versions of the guidelines. It is also recognized that the asthma care delivered by Chicago-area primary-care physicians may not reflect other communities or geographic areas.
Although there are limitations, this study helps to characterize many aspects of asthma care as delivered by primary-care physicians in a large urban environment. Many of the NAEPP guideline recommendations appear to have been incorporated into clinical practice, although others do not appear to have been readily adopted in this community. There are many possible explanations as to why widespread dissemination and awareness of guidelines do not always translate into clinical practice. Physician attitudes toward guidelines are key to their successful adaptation. One study has suggested that physicians increasingly view practice guidelines as primarily driven by cost-containment as opposed to quality improvement,22 and therefore may not be willing to change practices to meet what are perceived to be primarily economic outputs. Another study demonstrated that in one community, primary-care physicians disagreed with several aspects of the NAEPP guidelines.23 In the future, including more primary-care representation early in the process of guideline development and review may be a way to improve acceptability in this community of providers.
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Conclusion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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Appendix 1 |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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Acknowledgements |
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Footnotes |
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Abbreviations: AMA = American Medical Association; CASI =Chicago Asthma Surveillance Initiative; NAEPP = National Asthma Education and Prevention Program; PEFR = peak expiratory flow rate
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References |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionAppendix 1References |
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