Interventions to Modify Health Care Provider Adherence to Asthma Guidelines

Asthma is a respiratory disease characterized by variable and recurring symptoms, airflow obstruction, bronchial hyper-responsiveness, and inflammation of the airways. In the U.S., an estimated 24.6 million people (8.2 percent) currently have asthma. Students with asthma miss more than 14 million school days every year due to illness. In 2005, there were approximately 679,000 emergency room visits in the U.S. due to asthma in children under 15 years of age. Currently, asthma is the third leading cause of hospitalization among children in this age group. Furthermore, certain U.S. population subgroups have higher prevalence rates of asthma in comparison with the national average: children (9.6 percent), poor children (13.5 percent), non-Hispanic African American children (17.0 percent), women (9.7 percent), and poor adults (10.6 percent). Following asthma guideline treatment recommendations improves clinical outcomes in a variety of pediatric populations, including high-risk populations, such as inner-city, poor, and/or African American populations. The available evidence suggests that most people with asthma can be symptom-free if they receive appropriate medical care, use inhaled corticosteroids when prescribed, and modify their environment to reduce or eliminate exposure to allergens and irritants. Despite the evidence of improved outcomes associated with adherence to guidelines, their long-term existence (more than 20 years) and widespread availability, health care providers do not routinely follow asthma guideline recommendations. In one study, only 34.2 percent of patients reported receiving a written asthma action plan, while only 68.1 percent had been taught the appropriate response to symptoms of an asthma attack. In the same study, only about one third of children or adults were using long-term asthma controller medicine such as inhaled corticosteroids. Health care providers do not appropriately assess asthma control in most children, resulting in substandard care. Minority children are up to half as likely as Caucasian children to receive inhaled steroids. The significance of these studies is that suboptimal outcomes persist, such as twofold higher rates of emergency room visits for African American children compared with their Caucasian counterparts. With the lack of adherence to guideline recommendations, attention has been focused on why best practices are not followed (i.e., adhered to) by health care providers. The objective of our systematic review was to assess whether interventions targeting health care providers improve adherence to asthma guideline recommendations for asthma care and if these interventions subsequently improve clinical outcomes for patients. We also sought to determine whether any observed changes in asthma care processes directly improve clinical outcomes. This report has provided an organized systematic review of provider-focused interventions to improve asthma care and outcomes. Therefore, this report should provide a context in which to organize different types of interventions, their relative impact on a variety of outcomes, and considerations for what and how future studies should be planned. Our specific Key Questions (KQs) are listed below. KQ1: In the care of pediatric or adult patients with asthma, what is the evidence that interventions designed to improve health care provider adherence to guidelines impact health care process outcomes (e.g., receiving appropriate treatment)? KQ2: In the care of pediatric or adult patients with asthma, what is the evidence that interventions designed to improve health care provider adherence to guidelines impact clinical outcomes (e.g., hospitalizations, patient-reported outcomes such as symptom control)? KQ3: In the care of pediatric or adult patients with asthma, what is the evidence that interventions designed to improve health care provider adherence to guidelines impact health care process outcomes that then affect clinical outcomes?