The national guidelines have been widely disseminated, and a number of recent studies suggest that the vast majority of surveyed health care providers are aware of them (3-5). However, regardless of the widespread knowledge of these guidelines, mounting evidence indicates that physicians have not fully adopted them into practice (6-8). The article by Gipson et al provides additional evidence of the gap between the availability and use of asthma clinical care guidelines (9). The authors conducted chart audits to determine whether key processes related to asthma care were documented during routine patient visits. The authors report that many of the key elements of care were not routinely documented. They also note that although these performance measures appeared more frequently in the charts of asthma specialty clinics, even within that environment, there were clear opportunities to improve care. These findings, while interesting, are not all that unexpected. Several countries with well-established asthma care guidelines have documented (via chart audit) deficiencies in care for persons with asthma (10-12).

While there is some merit to further characterizing the lack of guideline adherence and variations in physician practices, the clear challenge for those concerned with improving asthma care lies in changing physician behavior and practice performance. The information obtained from the audit process provides a valuable foundation for discussing ways to improve care. It is critical to search for opportunities to use audit information to provide feedback that will lead to improvements in practice performance and, ultimately, better patient outcomes.

It is difficult to identify the most efficient mechanisms for achieving improvements in asthma care. There have been many attempts to encourage the adoption of practice guidelines and practice improvements; few have met the rigors of formal science. Yet there has been some demonstrated success in changing physician behavior through use of academic detailing, opinion leaders, physician feedback systems, and clinical decision support systems. These types of interventions, while useful to the individual physician, are perhaps best introduced through social learning networks such as community collaborations of providers focused on improving care (13).

Several studies of the use of feedback of audit information have reported improvements in care for persons with asthma (14, 15). Therefore, perhaps the most important opportunity derived from the study by Gipson et al rests not in the knowledge that there are areas where asthma care should be improved, but rather that the findings from clinical audits like these should serve as a first step in the journey towards practice improvement.

--Kevin B. Weiss, MD
Director, Center for Health Services Research
Rush Primary Care Institute

1. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health, 1991.
2. National Heart, Lung, and Blood Institute. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health, 1997.
3. Grant EN, Moy JN, Turner-Roan K, Daugherty SR, Weiss KB. Asthma care practices, perceptions, and beliefs of Chicago-area primary-care physicians. Chicago Asthma Surveillance Initiative Project Team. Chest 1999;116(4 Suppl 1):145S-154S.
4. Doerschug KC, Peterson MW, Dayton CS, Kline JN. Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med 1999;159:1735-1741.
5. Crain EF, Weiss KB, Fagan MJ. Pediatric asthma care in US emergency departments. Current practice in the context of the National Institutes of Health guidelines. Arch Pediatr Adolesc Med 1995;149:893-901.
6. Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KM. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med 1998;158:457-464.
7. Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG. Inadequate therapy for asthma among children in the United States. Pediatrics 2000;105(1 Pt 3):272-276.
8. Buchner DA, Carlson AM, Stempel DA. Patterns of anti-inflammatory therapy in the post-guidelines era: a retrospective claims analysis of managed care members. Am J Manag Care 1997;3:87-93.
9. Gipson JS, Millard MW, Kennerly DA, Bokovoy J. Impact of the national asthma guidelines on internal medicine primary care and specialty practice. BUMC Proceedings 2000;13:407-412.
10. McLeod SJ, Pearce MJ, Rigby SA, Begg EJ, Beard ME, Martin IR, Drennan CJ, Town GI. Asthma management at Christchurch Hospital: compliance with guidelines. N Z Med J 1996;109:115-118.
11. Pinnock H, Johnson A, Young P, Martin N. Are doctors still failing to assess and treat asthma attacks? An audit of the management of acute attacks in a health district. Respir Med 1999;93:397-401.
12. Jin RL, Choi BC. The 1996 and 1997 national survey of physician asthma management practices: background and study methodology. Can Respir J 1999;6:269-272.
13. Weiss KB, Mendoza G, Schall MW, et al. Improving Asthma Care in Children and Adults. Boston: Institute for Healthcare Improvement, 1997:167-197.
14. Collins S, Beilby J, Fardy J, Burgess T, Johns R, Booth B. The national asthma audit. Bridging the gap between guidelines and practice. Aust Fam Physician 1998;27:907-913.
15. Bryce FP, Neville RG, Crombie IK, Clark RA, McKenzie P. Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice. BMJ 1995;310:838-842.

sthma, an inflammatory disorder of the airways that leads to recurrent episodes of airflow obstruction and cough, is one of the most important health problems in the USA and other developed countries. The prevalence and mortality of asthma have risen steadily over the past decade despite significant advances in our understanding of the pathogenesis and treatment of this disorder (1). The impact of asthma is significant at the individual level, demonstrated by the presence of ongoing respiratory symptoms, reduced quality of life, and work and school absenteeism, and at a societal level by significant consumption of medical resources and substantial economic cost.

Both specialty and general providers deliver health care to individuals with asthma. Generalists, including internists, pediatricians, and family practitioners, provide care for the majority of individuals with asthma in the USA. Specialist providers, usually allergists and pulmonologists, are able to perform additional diagnostic tests, such as skin prick testing and full pulmonary function tests, that are appropriate for selected patients with asthma. The great majority of patients with asthma are thought to have mild to moderate disease severity and generally do not require additional testing; however, patients at all levels of asthma severity are at risk for severe asthma exacerbations, progression of disease severity, and chronic abnormalities in lung function if their asthma is not managed effectively.

To assist the practitioner in assessing and managing individuals with asthma, the National Heart, Lung, and Blood Institute's Asthma Expert Panel has developed a set of guidelines to provide an approach to asthma care. The expert panel report was based on the available scientific evidence and on expert opinion. The guidelines provide a structured approach to assess disease severity, apply pharmacological therapy, control exacerbating factors, and provide patient education. These guidelines were updated in 1997 in the second expert panel report (2).

In this issue of Baylor University Medical Center Proceedings, Gipson and colleagues performed a chart review to evaluate compliance with these guidelines in an asthma specialty clinic, a private pulmonary specialty practice, and a private general medical clinic (3). They found that there were significant shortcomings in the documentation of all the factors necessary to fully characterize the severity of asthma, especially in the general medical clinic. The assessment of factors that exacerbate asthma and education about asthma, including an exacerbation management plan, were also poorly documented in the charts from the general medical clinic. In the general medicine clinic, fewer patients were using inhaled corticosteroids, although this could reflect differences in disease severity between the primary care and subspecialty practices. These data suggest that the asthma guidelines are not being effectively implemented in the primary care setting and may result in underutilization of controller medications such as inhaled corticosteroids.

The study by Gipson, along with other studies, indicates that despite ongoing efforts to educate all asthma care providers about effective asthma treatment, there continues to be significant room for improvement, especially in the primary care setting. The challenge to the primary care physician is especially daunting, given the diversity of diseases encountered on a daily basis. A survey from a large health maintenance organization showed that individuals with asthma were receiving fewer prescriptions for controller medications than recommended by the expert panel guidelines and that less than half the participants were receiving education about avoiding asthma triggers, developing self-management plans, and using peak expiratory flow rate (PEFR) meters (4). Inhaled corticosteroids are recommended for the majority of patients with persistent asthma but are frequently not prescribed for these patients (4-6) and may not be used by patients unless they are adequately educated about the inflammatory nature of the disorder (4).

A survey of physician knowledge about the expert panel guidelines showed that the guidelines were better understood by asthma specialists than by primary care physicians, but all physicians in the survey, including the specialists, were unable to reiterate the panel's classification of severity (7). In a comparison of asthma management by allergists and generalists within a large health maintenance organization, there was greater use of controller medications such as inhaled corticosteroids in the patients from the allergy clinic, and despite greater disease severity in the allergy clinic population, there was a lower rate of exacerbations requiring emergency room care and improved quality of life defined by several dimensions of the Medical Outcomes Study--Short Form 36 questionnaire.

The scientific evidence that forms the basis of the asthma guidelines is very compelling. The early introduction of controller medications, most notably inhaled corticosteroids, reduces symptoms, improves quality of life, preserves lung function, and prevents exacerbations. For example, children with persistent asthma had a 1% to 3% decline in lung function per year measured by the forced expiratory volume in 1 second (FEV1) when treated with a bronchodilator alone, but similar children treated with the addition of inhaled budesonide experienced an annual increase in FEV1 of 3.9% (8). Adults similarly experience gains in FEV1 during treatment with inhaled corticosteroids, while a decline in FEV1 occurs during treatment with a bronchodilator alone (9). A delay in the introduction of inhaled corticosteroids results in a smaller improvement in FEV1 and greater airway hyperresponsiveness compared with individuals treated initially with an inhaled corticosteroid (10, 11). Early introduction of inhaled corticosteroids may preserve lung function through the inhibition of airway remodeling, which may be the cause of chronic airflow obstruction that occurs in some individuals with chronic asthma (12). Treatment with inhaled corticosteroids reduces subepithelial collagen deposits and the thickness of the lamina reticularis (13).

The role of patient education in the management of asthma is also compelling. An intervention consisting of education about asthma along with a written exacerbation management plan based on PEFR measurements significantly reduced the number of days lost from work, asthma exacerbations, urgent physician visits, and emergency room visits for asthma compared with a similar group of asthmatics without the educational intervention (14). A 12-month randomized trial of mild to moderate asthmatics showed that an educational program with an algorithm to adjust anti-inflammatory medications based on PEFR measurements improved quality-of-life scores, reduced the number of oral corticosteroid courses, reduced days missed from work, and reduced acute care visits (15).

Continuing efforts are necessary to provide optimal care to all patients with asthma. The guidelines developed by the asthma expert panel have a solid scientific foundation that if implemented properly will likely improve the outcome of asthma treatment. It is becoming clear that the asthma guidelines are not well understood by all physicians and that the guidelines are not being precisely followed. Asthma specialists adhere more closely to the asthma guidelines and appear to provide more effective asthma care but treat only a small fraction of the large asthma population. Future studies are necessary to determine the best way to educate providers about asthma therapy and to determine the impact of adherence to the guidelines on the outcome of asthma care. There is much to be gained in improving asthma care, both to the individual with asthma and to the health care system.

--Teal S. Hallstrand, MD, MPH
Division of Pulmonary and Critical Care
University of Washington

1. Mannino DM, Homa DM, Pertowski CA, Ashizawa A, Nixon LL, Johnson CA, Ball LB, Jack E, Kang DS. Surveillance for asthma--United States, 1960-1995. Mor Mortal Wkly Rep CDC Surveill Summ 1998;47:1-27.
2. National Heart, Lung, and Blood Institute. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health, 1997.
3. Gipson JS, Millard MW, Kennerly DA, Bokovoy J. Impact of the national asthma guidelines on internal medicine primary care and specialty practice. BUMC Proceedings 2000;13:407-412.
4. Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KM. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med 1998;158:457-464.
5. Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management. The Philadelphia story. Arch Intern Med 1997;157:1193-1200.
6. Vollmer WM, O'Hollaren M, Ettinger KM, Stibolt T, Wilkins J, Buist AS, Linton KL, Osborne ML. Specialty differences in the management of asthma. A cross-sectional assessment of allergists' patients and generalists' patients in a large HMO. Arch Intern Med 1997;157:1201-1208.
7. Doerschug KC, Peterson MW, Dayton CS, Kline JN. Asthma guidelines: an assessment of physician understanding and practice. Am J Respir Crit Care Med 1999;159:1735-1741.
8. Agertoft L, Pedersen S. Effects of long-term treatment with an inhaled corticosteroid on growth and pulmonary function in asthmatic children. Respir Med 1994;88:373-381.
9. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Lehtonen K, Nikander K, Persson T, Reinikainen K, Selroos O, et al. Comparison of a beta 2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. N Engl J Med 1991;325:388-392.
10. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Lehtonen K, Nikander K, Persson T, Selroos O, Sovijarvi A, et al. Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma. N Engl J Med 1994;331:700-705.
11. Overbeek SE, Kerstjens HA, Bogaard JM, Mulder PG, Postma DS. Is delayed introduction of inhaled corticosteroids harmful in patients with obstructive airways disease (asthma and COPD)? The Dutch Chronic Nonspecific Lung Disease Study Groups. Chest 1996;110:35-41.
12. Roche WR, Beasley R, Williams JH, Holgate ST. Subepithelial fibrosis in the bronchi of asthmatics. Lancet 1989;1:520-524.
13. Olivieri D, Chetta A, Del Donno M, Bertorelli G, Casalini A, Pesci A, Testi R, Foresi A. Effect of short-term treatment with low-dose inhaled fluticasone propionate on airway inflammation and remodeling in mild asthma: a placebo-controlled study. Am J Respir Crit Care Med 1997;155:1864-1871.
14. Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med 1995;151(2 Pt 1):353-359.
15. Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, Peramaki E, Poussa T, Saarelainen S, Svahn T. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ 1996;312:748-752.

reparation of the National Heart, Lung, and Blood Institute asthma guidelines was the initial process in educating the laity and the medical profession on the appropriate diagnosis and management of asthma (1). Dissemination is seldom adequate to create persistent alteration in physicians' or patients' behavior. One implementation strategy is use of computer-generated prompts in patient-encounter forms that remind the clinician to make specific inquiries or perform specific pulmonary function tests conforming to the guidelines. Evaluation of such programs is then required to assess compliance with the guidelines.

Evaluations such as the report provided by Gipson et al provide insight into the degree of guideline compliance by the principal care providers of asthma patients (2). In fact, the questions of this study permitted not only clinical appraisal but, more importantly, accurate definition of each patient's asthma severity. Although pulmonary specialists were most adept (64%) in adhering to the guidelines, the internists' assessment approached 58%. Evaluation of spirometry, rescue beta-agonist definition of asthma severity, pharmacotherapy, education, and definition of asthma triggers revealed similar disparities between asthma specialists (the pulmonary group) and internists.

Therefore, it is critical to emphasize the need for any clinic to document adherence to the asthma guidelines by periodic chart review that specifically targets defined inquiries. Physicians must be educated to inquire specifically, documenting symptom assessment as well as the use of objective parameters of assessment and, most importantly, defining asthma severity. Any further patient education procedures should be documented in the record as well.

Checklists for asthma patient therapy addressing the use of action plans, spacing devices, metered dose inhalers, environmental controls, and pharmacotherapy would provide a gentle reminder to the asthma caregiver at each visit.

The requirement for pulmonary functional assessment at each visit cannot be overemphasized. It is now well documented that physicians cannot adequately diagnose asthma severity only by clinical assessment. Therefore, such functional assessment is requisite for proper evaluation of asthma severity and, in turn, for appropriate therapeutic intervention. In fact, in this study only 33 of 114 charts of asthma patients contained complete spirometric data (2). This emphasizes the need for such information, first to establish a diagnosis and then to properly define therapeutic intervention.

The relevance of clinical guidelines to therapeutic outcomes, such as reduced morbidity or prevention of mortality, is not the issue here. However, without proper compliance with appropriate therapy, it is doubtful that significant reduction in these parameters can be obtained.

Update of the guidelines will now provide more scientifically valid data derived from evidence-based inquiries. But defining guideline compliance may be difficult. Therefore, by providing an outline of inquiries germane to the asthma patient outcome in a checklist, guideline compliance should be enhanced, and in particular, a definition of severity establishing the level of asthma care intervention can be provided.

Of course, documentation of provided care is often lacking, and notes often fail to reflect the extent of the care. But in today's managed care environment, published studies such as this only serve to emphasize the need for detailed documentation of every aspect of delivered care. For asthma, such therapeutic endeavors must begin with a definition of severity. In so doing, a more uniform application of therapy can be derived from guidelines and applied appropriately. As the authors mentioned, continuing medical education, including use of chart flow sheets or at least a checklist with reminders of recommendations, will provide enhanced care. Similarly, educational endeavors for the laity may help reduce asthma morbidity further and eventually prevent asthma mortality.

--Albert L. Sheffer, MD
Division of Rheumatology, Immunology,
and Allergy, Department of Medicine
Brigham and Women's Hospital

1. National Heart, Lung, and Blood Institute. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health, 1997.
2. Gipson JS, Millard MW, Kennerly DA, Bokovoy J. Impact of the national asthma guidelines on internal medicine primary care and specialty practice. BUMC Proceedings 2000;13:407-412.