From the Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas.

Corresponding author: J. Scott Gipson, MD, Department of Internal Medicine, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246.

Over recent years, several studies have attempted to determine the impact of the NAEPP guidelines on asthma management (4-8). These studies have most often used patient and physician questionnaires to assess guideline compliance, with few studies giving attention to chart content. We designed this study to determine whether there was chart documentation of guideline compliance.

METHODS

Study sample

Our study was designed to determine whether NAEPP guidelines were reflected in patient records. After obtaining institutional review board approval, we used the 4 components emphasized in the Expert Panel Report 2 to retrospectively review outpatient medical records in a hospital-based asthma subspecialty clinic, a private pulmonology group, and a general internal medicine group. Charts were selected using the International Classification of Diseases (ICD)-9 codes 493.00, 493.10, 493.01, and 493.90. Chart lists were generated in a consecutive fashion from billing files of the most recent patient encounters with these ICD-9 codes. Patients who had been in physician practices <5 months were excluded from the study. Additionally, any patient who did not appear to have received primary asthma care from the clinic in review was excluded.

Chart review

Chart review was accomplished using a multipoint evaluation scheme generated from Expert Panel Report 2. Each component in this report was represented by several patient care issues (Table 1). The reviewer had access to the entire outpatient chart, including physician notes, laboratory values, questionnaires, and diagnostic study results.

Analysis

All analyses were performed using the Statistical Program for the Social Sciences 9.0 statistical software package (SPSS Inc, Chicago, Ill). We used nonparametric tests to analyze our data. The chi-square test was used to compare categorical data, and the Mann-Whitney U statistic was used to compare ordinal data. All P values are 2-sided and are reported as significant if P < 0.05.

RESULTS

A total of 114 charts were reviewed, including 40 from a hospital-based asthma specialty clinic, 36 from a private pulmonary group, and 38 from a private internal medicine group.

Demographics

There was a significant difference when comparing patient age between the pulmonary group and internal medicine group (Table 2). Additionally, years followed at the clinic showed a statistically significant difference, with the internal medicine group having the longest patient follow-up (6.2 ? 6.5 years), compared with 4.0 ? 4.9 years for the pulmonary group and 2.5 ? 2.3 years for the asthma clinic.

Assessment and monitoring

While nearly all physicians documented inquiries about daytime asthma symptoms, nighttime symptoms were documented in 98% of asthma clinic charts, 64% of pulmonary group charts, and 58% of internal medicine charts (Table 3). Spirometry, also vital in diagnosing asthma and assessing degree of severity, was present in all asthma clinic charts and 86% of pulmonary group charts, but only 26% of internal medicine charts. Likewise, peak flow data were present in <30% of pulmonary group and internal medicine charts. The presence of documentation for rescue beta-agonist requirements ranged from 93% of asthma clinic charts to 55% of internal medicine charts, and the presence of comments on asthma severity ranged from 68% of asthma clinic charts to 29% of internal medicine charts.

Control of factors

While inquiries about asthma triggers were documented in 98% of asthma clinic charts, the frequency was significantly lower in the other groups, with 75% in the pulmonary group and 42% in the internal medicine group (Table 4). However, internal medicine and pulmonary group charts were more likely than asthma clinic charts to document administration of the influenza vaccine.

Pharmacotherapy

All asthma clinic patients were on inhaled steroids as of their last recorded visit, compared with 94% of pulmonary group patients and 66% of internal medicine patients (Table 5). We also reviewed the dosage given to the subgroup of patients with severe, persistent asthma, defined as spirometry showing >=1 forced expiratory volume in 1 second (FEV1) <60%. Twenty-three of the patients in the asthma clinic group fit this description: 17 were on high-dose and 6 on moderate-dose inhaled steroids. In the pulmonary group, 12 of 32 patients were in the severe subgroup: 3 were on high-dose therapy, 5 on moderate-dose therapy, and 2 on low-dose therapy; 1 patient's dose was not recorded, and 1 was not on inhaled steroids. In the internal medicine group, 3 patients were in the severe subgroup: 1 was on moderate-dose therapy, and 2 were on low-dose therapy. (See p. 88 of reference 3 for definitions of high, medium, and low doses of inhaled steroids.)

Education

For all evaluation points, the asthma clinic group had better documentation of patient education issues (Table 6). The asthma clinic group documented the 4 educational interventions 65% to 83% of the time, compared with the pulmonary group, at 17% to 50%, and the internal medicine group, at 5% to 18%. The pulmonary group did significantly better than the internal medicine group in documenting an exacerbation plan and in suggesting ways to control the environment. Suggestions included washing linens in hot water to decrease dust mite load, exterminating cockroaches, or removing pets from indoors.

DISCUSSION

Our study showed that the asthma clinic group tended to be most compliant with the guidelines in terms of documentation of symptom assessment, use of objective measures to diagnose and monitor asthma, and assignment of severity level. Patient education issues were most frequently documented in the asthma clinic group as well.

Possible explanations for the above findings include the use of a chart checklist and nonphysician case managers by the asthma clinic group. Chart checklists specifically addressed action plans, spacing device use, metered-dose inhaler instruction, environmental control, and medication teaching and served as a reminder to perform these aspects of asthma care each visit. Interestingly, the influenza vaccine was not on the visit checklist. This may explain why the asthma clinic performed poorly in that area.

The results for each component of the study are telling. Regarding component 1, assessment and monitoring, the recording of day symptoms and the lack of spirometry or peak flow data suggest that some physicians may be using symptomatology as a guide to diagnosing asthma. The 1997 NAEPP guidelines report, “Objective assessments of pulmonary function are necessary for the diagnosis of asthma because medical history and physical exam are not reliable means of excluding other diagnoses or of characterizing the status of lung impairment” (3). Russel et al suggested that physicians, without objective spirometric data, were able to correctly assess a lung abnormality as obstructive but poorly assessed whether the obstruction was reversible (9).

Furthermore, FEV1 or peak flow data, like nocturnal symptoms, are key information in assessing degree of asthma severity. Shim and Williams reported that physicians have a poor ability to assess the degree of airflow obstruction using only history and physical exam (10). Therefore, the NAEPP expert panel felt that it was necessary to include FEV1 and peak flow data, in addition to symptomatology, in the assessment of asthma severity. Degree of severity is, in turn, a cornerstone to determining proper pharmacotherapy, as suggested in the guidelines. Using day symptoms alone, many physicians are employing only 1 of 3 recommended data elements to determine asthma severity. Possible explanations to these findings include lack of physician familiarity with the 1997 NAEPP guidelines, lack of accessibility of spirometry equipment, increasing restraints on physician time, or a feeling among physicians that the guidelines are overly intensive and impractical.

The second component of asthma care involves an attempt to control factors contributing to asthma severity. A key factor in determining what asthma patients should avoid is a detailed history of triggers. Most asthma clinic and pulmonary group charts (98% and 75%, respectively) contained this history, while less than half of internal medicine charts contained a trigger history. Another factor known to incite an exacerbation of asthma is viral upper respiratory illness (11). The NAEPP guidelines recommend that patients with persistent asthma receive yearly influenza vaccinations (3). Approximately one quarter of pulmonary group and internal medicine charts documented the influenza vaccine for the 1998 to 1999 season, while 13% of asthma clinic charts contained this data. (Note that follow-up for some patients in the study was not long enough to show administration of the influenza vaccine, since the study took place in September 1999 and included some patients who had been seen by the physician for only 5 months.)

In component 3, the 1997 NAEPP guidelines classify asthma severity and match medication selection and dose to degree of severity. For example, a patient with moderate persistent asthma (FEV1 60% to 80% predicted) would be on at least a low or medium dose of inhaled steroids. We reviewed charts that documented spirometry to determine the lowest FEV1 recorded in the chart. Of 38 patients with >=1 recorded FEV1 <60% predicted, all but 1 were on inhaled steroids. Twenty of the 38 patients were on high-dose inhaled steroids. These data suggest that most physicians are aware of the need for anti-inflammatory drugs when choosing pharmacotherapy for patients with objective measures of asthma severity. However, the issue remains that 33 of 114 charts labeled as “asthma” did not contain full spirometric data, therefore making proper choice of pharmacotherapy extremely difficult.

The final component of asthma care suggested by Expert Panel Report 2 is patient education. The report states, “Patient education should begin at the time of diagnosis and be integrated into every step of clinical asthma care” (3). Additionally, all members of the health care team are encouraged to participate in asthma education. One of the simplest and most important aspects of asthma education concerns proper administration of medicines (3, 12). Correct use of inhalers and spacers ensures delivery of medication to the airways. Proper technique and spacer use documentation were seen most frequently in the asthma clinic group, followed by the pulmonary group and internal medicine group.

The expert panel has also recommended that exacerbation plans be provided to patients in written form (3). This provides the patient with more independence in asthma management and can quickly attenuate any decompensation in function. Even though substandard to the asthma guidelines, credit was given for an exacerbation plan if the physician documented so much as an instruction for the patient to call for asthma problems. Despite this more liberal approach, exacerbation plans were noted in 80% of asthma clinic charts, 50% of pulmonary group charts, and 18% of internal medicine charts.

The guidelines on patient education place a significant burden on physicians treating asthma. Since primary care physicians treat such a broad spectrum of diseases, it may be unreasonable to ask these physicians to equip their practice with such an intensive education program. In fact, case managers under the supervision of a physician accomplished much of the patient education performed in the asthma clinic group. Perhaps asthma--like diabetes mellitus in chronicity, varying severity, and need for long-term management--will become a disease for which education centers are available.

Our study specifically did not address patient outcomes, nor were we attempting to prove that patients who have been managed according to the guidelines have better outcomes. To directly correlate quality of care to documented guideline compliance would not be appropriate. Determining whether patient management based on the guidelines would improve patient outcome would be an interesting study but would require a very different approach than the one we have chosen. Certainly, significant debate exists about whether clinical guidelines actually improve patient care. As referenced in the guidelines (p. 2), many of the recommendations are evidenced based and have demonstrated patient benefit; however, other suggestions are “based on the opinion of the Expert Panel” and lack randomized clinical trials (3). The issue of clinical practice guideline utilization has been reviewed in the recent literature (13).

One potential limitation of this study is failure of our assessment tool (chart abstraction) to accurately reflect guideline compliance. Multiple approaches have been reviewed in an attempt to define the best evaluation of physician practices. A recent article examined the pros and cons of vignettes, standardized patients, and chart abstraction (14). One of the cons of chart abstraction is the failure of physicians to document care that was provided. This could apply to some of our evaluation points, such as teaching of correct metered-dose inhaler use or inquiry about nocturnal symptoms. However, other evaluation points, such as spirometry measurements, peak flow data, and vaccination records, would certainly be expected to have been recorded if performed. The issue of careful documentation is an important aspect of patient care, which has been previously reviewed (15).

Another potential limitation is the classification of severity by FEV1 measurement. Although these charts did contain at least one FEV1 <60% predicted, the measurement could have fallen during an exacerbation period, therefore making the degree of asthma severity appear worse than it usually was. However, this variable was chosen because it would suggest that such a patient, at the very least, would have severe asthma exacerbations, making anti-inflammatory therapy appropriate. Indeed, the data supported that almost all patients in this category were on inhaled steroids.

Finally, it should be noted that we did not stratify patients according to risk when comparing the 3 clinic groups. An attempt was made to exclude those patients who appeared to receive their primary asthma care from a referral clinic. This could have led to some selection bias in that the patients of the primary care group with more severe asthma were referred to a specialist. In turn, we would be left with a population in the primary care group that had less severe asthma and, perhaps, less intensive care for less severe disease. However, it was felt that this approach was necessary since a patient who received asthma care from a referral clinic could not be accurately evaluated in the referring clinic. Furthermore, we did not feel that comparing documentation of these process of care measures required risk stratification. The guideline recommendations we included in the study generally applied to asthma patients across the spectrum of severity. However, if a study were undertaken that evaluated patient outcome in these clinics, risk stratification would be necessary (16).

Asthma is a complex disease that carries significant morbidity and mortality. Since 1991, physicians have had a powerful resource available through the Guidelines for the Diagnosis and Management of Asthma (2, 3). However, as demonstrated now in several types of studies (4-8), uniform application of these guidelines has yet to be accomplished. Potential techniques to implement these standards of asthma care need to be explored. Possibilities include continuing medical education to familiarize physicians with the guidelines (17), chart flow sheets and checklists to remind physicians of recommendations, and the establishment of education centers where patients and their families could be taught principles of asthma care. Furthermore, the general usefulness of clinical practice guidelines needs to be examined more closely.

Acknowledgment

The authors would like to express their appreciation to those physicians who chose to participate in this study. Without a doubt, their willingness to participate demonstrated their desire to provide quality patient care.

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