Primary care-based program can help improve assessment and treatment of asthma in children

An innovative primary care-based asthma program improves identification of poorly controlled asthma among children and enhances treatment plans, compared to care provided during routine office visits, according to research published in the current edition of the Journal of Asthma.

Researchers from the Children's Hospital at Montefiore (CHAM), conducted a retrospective study, assessing the severity of asthma in 79 children, 5 - 19 years of age, during routine healthcare visits as compared to the severity of asthma assessed during a visit to a dedicated asthma program in which The Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma was utilized. The EPR-3 guidelines recommend that clinicians ask five standardized questions, such as asking about asthma symptoms and use of rescue medication; and that they administer spirometry - a test to measure airflow during exhalation - during the appointment.

Findings showed:
- Among children referred to the asthma program, the majority of whom were Latino or African American, more were identified with moderate or severe asthma than had been identified during routine care.
- Responses to the clinical questions showed that 47.9 percent of participants had moderate or severe persistent asthma.
- Spirometry, which is not typically carried out in pediatric primary care settings due to insufficient time and training of staff, identified 56.9 percent of participants as having moderate or severe persistent asthma.
- When results from asking the questions and administering spirometry were combined, 75.3 percent of participants were identified as having moderate or severe persistent asthma. This is compared to only 15.2 percent who had been identified as having moderate or severe asthma during routine care.
- After a visit to the asthma program more children were prescribed controller medications and had their medication plans revised to match their asthma severity.

"An estimated seven million children in the U.S have asthma and almost half are poorly controlled," said Karen Warman, M.D., lead author and attending physician at the Comprehensive Family Care Center (CFCC), one of CHAM's outpatient sites, and associate professor of Clinical Pediatrics at Albert Einstein College of Medicine. "Our study highlights that asthma severity is under-recognized and undertreated during routine care, and access to a dedicated asthma program can improve both assessment and treatment, which could ultimately improve quality of life and decrease hospitalizations and cost."

Previous research has shown that asthma accounts for an estimated 10.5 million missed school days, 640,000 emergency department visits and 157,000 hospitalizations for children each year. In this study, the percent of children who had an emergency department visit for asthma decreased from 32 percent in the 12 months before the asthma program visit to 8 percent after the asthma program visit.

Dr. Warman, a pediatric generalist with expertise in asthma management, leads the Pediatric Preventive Asthma Care Program at CFCC along with a nurse who is trained as an asthma coach and assists with conducting the spirometry testing (which is not provided at this primary care site outside of the asthma program). Patients are referred to the asthma program and visits are approximately 30 minutes in duration. At the initial asthma program visit, all children have baseline spirometry testing performed, the asthma specialist evaluates each child, interprets the spirometry results, and uses an electronic medical record (EMR) template to classify asthma severity. The asthma program visit notes are shared with the referring primary care provider through the EMR and follow-up care is arranged with either the asthma program physician or the primary care provider.

"We recognize many demands are placed on primary care physicians during routine health care maintenance visits," said Dr. Warman. "For this reason, we recommend arranging separate asthma-focused visits, which allow more time to speak with families, assess for environmental exposures, discuss medications, and demonstrate correct use of spacer devices."

The researchers believe that primary care providers, because they provide longitudinal, family-centered care, are uniquely poised to identify children at risk for asthma morbidity and to partner with families in the long-term management of asthma. However, appropriate time and support must be dedicated to address asthma as a chronic illness in the primary care setting in order to help children and families achieve asthma control.