Survey of Asthma Practice Among Emergency Physicians

doi:10.1378/chest.109.3.708

Chest

Volume 109, Issue 3, March 1996, Pages 708-712

https://doi.org/10.1378/chest.109.3.708 Get rights and content

Purpose

The National Asthma Education and Prevention Program (NAEPP) published guidelines for asthma management in 1991. The purpose of this study is to assess the concordance between emergency physicians' practice and the guidelines.

Design

Survey mailed to emergency physicians. Nonrespondents were mailed a second copy of the survey.

Participants

Eight hundred randomly selected active members of the American College of Emergency Physicians.

Interventions

None.

Measurements

Participants were asked questions regarding training, current asthma practices, and sources of information on asthma management.

Results

Eight hundred questionnaires were mailed, of which 416 (52%) were returned. Sixty-four percent of respondents administer β-agonists consistent with the NAEPP guidelines. Seventy-five percent of respondents administer corticosteroids in similar accord, while 75% prescribed outpatient corticosteroids in concordance with those recommendations. Fortyseven percent report measuring pretreatment pulmonary function more than half the time and only 38% report checking pulmonary function prior to disposition more than half the time.

Conclusions

Most emergency physicians surveyed use β-agonists and steroids at least as often as recommended. A minority of emergency physicians reported utilizing pulmonary function testing in the manner recommended by the NAEPP.

Section snippets

Materials and Methods

A survey instrument was designed containing questions covering the respondent's training background, nature of clinical practice, use of medications for acute asthma, and use of PFT. Most of the questions were multiple choice and covered pertinent aspects of the guidelines for ED management of asthma. In addition, questions were included covering the sources of information physicians used to guide asthma management. A pilot study of the survey was performed with a mailing to a random sample of

Results

Of 800 (52%) surveys, 416 were returned; 298 (72%) respondents were board certified in emergency medicine (EM) and 56 (13%) were board prepared in EM (Table 2). In addition, 133 (32%) were board certified and 21 (5%) were board prepared in another specialty; 199 (48%) respondents had completed a residency in EM.

Fifty-five (13%) of those surveyed practice in a university or governmental teaching hospital, 79 (19%) practice in other teaching hospitals, 258 (62%) practice in community hospitals,

Discussion

Recommendations for changes in asthma management have been widely reported. There has, however, been little work undertaken to assess the effect of these published guidelines on actual practice. This study demonstrates that most emergency physicians follow the treatment but not the assessment guidelines as published.

Some work has been performed to assess the success of guidelines in influencing management in other countries. The British Thoracic Society has published a stepwise approach to

Conclusion

Emergency physicians report use of corticosteroids and inhaled β-agonists at least as often as recommended by the guidelines. There is less concordance with the NAEPP recommendations for measurement of PFTs. Educational efforts and research efforts should highlight the importance of PFT, in light of information that demonstrates its effect on the management of acute asthma.

References (19)

JacksonR et al.
International trends in asthma mortality: 1970 to 1985
Chest
(1988)
GibsonP
Asthma guidelines and evidence-based medicine
Lancet
(1993)
ChidleyKE et al.
Reassessment of asthma management in accident and emergency department
Respir Med
(1991)
EmermanCL et al.
Physician estimation of FEV1 in acute exacerbation of COPD
Chest
(1994)
ShimCS et al.
Evaluation of the severity of asthma: patients versus physicians
Am J Med
(1980)
NowakRM et al.
Spirometric evaluation of acute bronchial asthma
J Am Coll Emerg Phys
(1979)
SheferAL et al.
The National Asthma Education Program: expert panel report guidelines for the diagnosis and management of asthma
Med Care
(1993)
Medical news and perspectives: international consensus report urges sweeping reform in asthma treatment. JAMA 1992;...
NIH asthma treatment guidelines not being utilized in patient care. W Va Med J 1993;...

There are more references available in the full text version of this article.

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These are relatively simple to perform, are an objective assessment of airflow, and have been extensively studied. However, the exact cut-off value for these tests to optimize sensitivity and specificity for the need for hospitalization has been debated [2,14,27] and ranges from <50% predicted to <25% predicted. Perhaps as a result of this wide variation in a “safe for discharge” %FEV1 its use for disposition decision making is not widespread.
(1) Compare ideal cut-off points for DS and %FEV₁ at 1 and 3 h to predict hospitalization/relapse in subjects with moderate to severe asthma exacerbation (2) Develop a multivariate regression model using DS, %FEV₁, demographic, and clinical variables to predict hospitalization/relapse.
Subjects with acute exacerbation of asthma (FEV₁ <50% predicted following 30 min of standardized treatment: 5 mg nebulized albuterol; 0.5–1.5 mg nebulized ipratropium; and 50 mg oral prednisone) were eligible. All subjects had %FEV₁ and DS obtained at baseline and hourly for 3 h. Using hospitalization/relapse as the outcome of interest; we compared the area under the receiveroperator curves (AUC) between the 1 and 3 h DS and %FEV₁ measurements, and the AUC for the change in DS and %FEV₁ between baseline and hour-3. We determined ideal cut-points for %FEV₁ and DS to maximize sensitivity and specificity. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LR) were compared between %FEV₁ and DS. We developed a multivariate regression model examining the association of specific demographic and clinical variables to hospitalization/relapse.
142 patients were included for analysis. The AUC was greatest for the 3-h DS (0.721), followed by the 3-h %FEV₁ (0.669). Optimum cut-off values were a DS of 2, and an FEV₁ of 42%. These were associated with a +LR for the composite outcome of 3.06 and 2.48 respectively. Logistic regression showed baseline DS, 3-h DS, change in DS, and oxygen use at hour 3 were all associated with the composite outcome.
The 3-h score for %FEV₁ and DS performed better than scores at any other time point and better than either parameter over time. The 3-h DS had the greatest association with the composite outcome. Neither test was a strong enough predictor to be used solely for this purpose.
Does guideline knowledge affect treatment compliance among emergency doctors?
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The insufficient adoption of internationally accepted clinical guidelines may lead to less than adequate patient care of patients with asthma.
To evaluate the knowledge and treatment compliance with Global Initiative of Asthma (GINA, 2011) asthma treatment guidelines among emergency physicians (EPs) at a referral hospital in northern Malaysia.
A cross-sectional study was designed in the territory-level referral hospital in northern Malaysia. Twenty-seven EPs were asked to complete an asthma guideline questionnaire to assess their knowledge regarding GINA 2011 asthma treatment guidelines. A total of 810 patients were enrolled, and 30 patients were selected per physician. The authors evaluated the physicians’ compliance with GINA 2011 asthma treatment guidelines.
Of 27 EPs, 20 (74.1%) had adequate knowledge of GINA 2011 asthma treatment guidelines. A total of 615 (75.9%) patients received guideline-recommended emergency treatment. Shortness of breath (n = 436, 53.8%) was the most frequently reported chief complaint. Furthermore, there was a significant but weak association between knowledge of the guideline and treatment compliance among emergency doctors (P = 0.003, φ = 0.110). Moreover, there was no significant change in therapy for patients with comorbid conditions. The mean age of respondents was 27.3 years.
Overall, a fair level of guideline knowledge and treatment compliance was noted among EPs. Doctors with adequate guideline knowledge were more likely to comply with GINA 2011 asthma treatment guidelines.
Pregnancy related treatment disparities of acute asthma exacerbations in the emergency department
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Asthma is one of the most common medical conditions complicating pregnancy. Despite the presence of published guidelines outlining the care of the pregnant patient with asthma, disparities in the treatment of acute asthma exacerbations in the emergency department related to pregnancy status are known to exist. We sought to determine if pregnancy status affected the treatment of women presenting to a tertiary emergency department for care of acute asthma exacerbations.
We retrospectively compared the emergency department treatment of acute asthma exacerbations in 123 pregnant women to 123 non-pregnant controls. Asthma exacerbations were classified by severity according to pre-determined criteria.
In the emergency department (ED), pregnant women were significantly less likely to be treated with systemic corticosteroids than non-pregnant controls (50.8% versus 72.4%, p = 0.001). Similarly, 41% of pregnant women received prescriptions for prednisone at the time of discharge from the ED compared to 69.2% of non-pregnant women (p < 0.001).
In this population of asthmatics presenting to a tertiary emergency department with acute asthma exacerbations, pregnant women were less likely to receive appropriate therapy with systemic corticosteroids.
Inadequate follow-up controller medications among patients with asthma who visit the emergency department
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Citation Excerpt :
Although Stempel et al11 investigated prescription patterns for 2 months after an ED visit and demonstrated that the increase in prescriptions for inhaled corticosteroids after an ED visit reverted to baseline rates in the second month after the index visit, we demonstrate that prescriptions rates remain low for at least a year after the visit. Possible reasons for this include failure of many patients to follow up after an ED visit, lack of physician familiarity with the guidelines, lack of agreement with guidelines, complexity of the guidelines, and failure to apply them correctly.25-33 Although a visit to the ED represents a failure of the NAEPP EPR-2 goals, it also represents an opportunity to improve asthma care.
The purpose of this study is to determine the frequency with which primary care physicians add inhaled corticosteroids to the regimen of asthmatic patients after a visit to the emergency department (ED) among patients not previously prescribed inhaled corticosteroids and to determine the rate at which inhaled corticosteroids prescribed in the ED were continued by primary care physicians.
We conducted a structured retrospective cohort study using electronic medical record review of consecutive patients aged 6 to 45 years, treated for acute asthma exacerbation (International Classification of Diseases, Ninth Revision code 493.00 through 493.99) in the ED during a specified 6-month period, and followed up for 1 year. The patients' first ED visit for asthma exacerbation during the study period was considered the index visit for purposes of this study.
Six hundred twenty-nine patients met study inclusion criteria, 414 of whom were not previously receiving inhaled corticosteroid therapy. On ED or hospital discharge, 99 (24%) of these 414 patients were prescribed an inhaled corticosteroid. Of these 99 patients, 37 patients had a primary care follow-up visit within 6 months, with 4 receiving an inhaled corticosteroid dose change and no patients having the inhaled corticosteroids discontinued. Of the 315 patients not prescribed an inhaled corticosteroid on ED or hospital discharge, 128 had a primary care follow-up visit within 6 months, with 32 (25%) patients having an inhaled corticosteroid added to their therapeutic regimen. After primary care follow-up, only 69 (42%) of the 165 patients treated in clinic were receiving an inhaled corticosteroid for control of their asthma. Patients without insurance (odds ratio 0.14; 95% confidence interval 0.027 to 0.71) and patients initially discharged home from the ED (odds ratio 0.17; 95% confidence interval 0.05 to 0.53) were much less likely to receive inhaled corticosteroids at follow-up on multivariate logistic regression adjusting for race, sex, insurance status, and initial disposition.
Primary care physicians infrequently add controller medications (inhaled corticosteroids) at follow-up to the regimen of asthmatic patients after a visit to the ED. Emergency physicians should be encouraged to evaluate chronic asthma burden among patients presenting with exacerbation, educate asthmatic patients, and prescribe controller medications, such as inhaled corticosteroids, for those with persistent symptoms.
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All patients with asthma are at risk of having exacerbations. Hospitalizations and emergency department (ED) visits account for a large proportion of the health-care cost burden of asthma, and avoidance or proper management of acute asthma (AA) episodes represent an area with the potential for large reductions in health-care costs. The severity of exacerbations may range from mild to life threatening, and mortality is most often associated with failure to appreciate the severity of the exacerbation, resulting in inadequate emergency treatment and delay in referring to hospital. This review describes the epidemiology, costs, pathophysiology, mortality, and management of adult AA in the ED and in the ICU.

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: revision accepted October 18.

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Chest

Clinical Investigations: AsthmaSurvey of Asthma Practice Among Emergency Physicians

Purpose

Design

Participants

Interventions

Measurements

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Chest

Lancet

Respir Med

Chest

Am J Med

J Am Coll Emerg Phys

The National Asthma Education Program: expert panel report guidelines for the diagnosis and management of asthma

Med Care

Clinical Investigations: Asthma
Survey of Asthma Practice Among Emergency Physicians