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Adherence to Guidelines Varies in Treatment of Pediatric Asthma

http://www.medscape.com/viewarticle/718488?src=rss

Adherence to Guidelines Varies in Treatment of Pediatric Asthma

March 15, 2010 (Anaheim, California) — Clinicians vary widely in their adherence

to evidence-based guidelines for treating children with asthma, Angeline Ti

reported in a poster session here at the American Medical Student Association

60th Annual Convention.

In some cases, following the guidelines had no impact on clinical outcomes, said

Ms. Ti, a second-year student at the University of Michigan Medical School in

Ann Arbor.

For her study, Ms. Ti reviewed the records of 200 randomly selected children,

aged 2 to 18 years, admitted to the University of Michigan Hospital System for

asthma exacerbations from January 1, 2007 to June 30, 2009.

To evaluate quality of care, each case was examined for inpatient use of

systemic corticosteroids, short-acting beta-agonists (SABAs), and asthma action

plans. All of these are listed as quality measures for pediatric asthma

treatment by Hospital Compare, which Ms. Ti defined as " a national dataset

provided by Medicare for patients to compare the quality of patient care across

hospitals. " She hypothesized that adherence to these measures would be

associated with better outcomes, defined as fewer revisits and readmissions.

Virtually all of the children (99%) received a SABA at some time during their

hospital stay, and nearly as many (92.5%) received a systemic corticosteroid.

However, only 46% of the patients were discharged with a written asthma action

plan. Furthermore, 36% of the patients revisited their asthma clinician or the

emergency department within 1 year of hospitalization for an acute asthma

exacerbation, and 16% of the patients required readmission.

" Failure to receive a SABA or oral corticosteroids was perfectly associated with

not being readmitted to the hospital, " Ms. Ti reported in her poster. Keeping

follow-up appointments with the child's primary asthma care provider

significantly reduced their chances of revisits or readmission, whereas

admission to the pediatric pulmonary care unit or intensive care unit increased

the risk for subsequent readmission.

In addition to showing a wide variation in adherence to the guidelines, these

findings suggest that better outcomes do not necessarily result when the

guidelines are observed, Ms. Ti said. " This could be less a problem with the

guidelines and more a problem with having good measurable outcomes, " she told

Medscape Med Students. She also pointed out that, as a chronic illness, asthma

is managed largely by patients and their families themselves, so that " many of

the outcomes depend less on what the doctor does and more on the home

environment and what the patient does. "

It is also possible that the few children who did not receive steroids were less

seriously ill, said Henry Milgrom, MD, professor of pediatrics at National

Jewish Health in Denver, Colorado. " There is no question that patients with

asthma who receive steroids do better than those who don't. Most doctors would

give steroids during and after hospital admission, so the kids who did not get

them may not have had asthma at discharge. "

The guidelines do have their flaws, although they are always being improved,

said Dr. Milgrom, who was not involved in this study. Currently, the guidelines

are too long and too difficult to wade through during a busy clinical

consultation. They do not include management of important cases, such as

patients with allergies, and they do not pay enough attention to conditions that

can mimic or coexist with asthma. " But overall, people with asthma need

steroids. There's nothing else that's better. "

" Initially, I was disappointed " at the spotty adherence to the guidelines, Ms.

Ti admitted. Ultimately, however, she realized that many other variables are

involved. " There's a lot more that goes into how well a child can control their

asthma than whether or not they receive a certain medication. "

American Medical Student Association (AMSA) 60th Annual Convention: Abstract 25.

Presented March 11, 2010.

Authors and Disclosures

Journalist

Norra MacReady

Norra MacReady is a freelance medical writer for Medscape.

Medscape Medical News © 2010 Medscape, LLC

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