Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Objectives Despite the broad range of continuing medical education (CME) offerings aimed at educating practicing physicians through the provision of up-to-date clinical information, physicians commonly overuse, under-use, and misuse therapeutic and diagnostic interventions. It has been suggested that the ineffective nature of CME either accounts for the discrepancy between evidence and practice or at a minimum contributes to this gap. Understanding what CME tools and techniques are most effective in disseminating and retaining medical knowledge is critical to improving CME and thus diminishing the gap between evidence and practice. The purpose of this review was to comprehensively and systematically synthesize evidence regarding the effectiveness of CME and differing instructional designs in terms of knowledge, attitudes, skills, practice behavior, and clinical practice outcomes. Review methods We formulated specific questions with input from external experts and representatives of the Agency for Healthcare Research and Quality (AHRQ) and the American College of Chest Physicians (ACCP) which nominated this topic. We systematically searched the literature using specific eligibility criteria, hand searching of selected journals, and electronic databases including: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Abstracts of Reviews of Effects (DARE), PsycINFO, and the Educational Resource Information Center (ERIC). Two independent reviewers conducted title scans, abstract reviews, and then full article reviews to identify eligible articles. Each eligible article underwent double review for data abstraction and assessment of study quality. Results Of the 68,000 citations identified by literature searching, 136 articles and 9 systematic reviews ultimately met our eligibility criteria. The overall quality of the literature was low and consequently firm conclusions were not possible. Despite this, the literature overall supported the concept that CME was effective, at least to some degree, in achieving and maintaining the objectives studied, including knowledge (22 of 28 studies), attitudes (22 of 26), skills (12 of 15), practice behavior (61 of 105), and clinical practice outcomes (14 of 33). Common themes included that live media was more effective than print, multimedia was more effective than single media interventions, and multiple exposures were more effective than a single exposure. The number of articles that addressed internal and/or external characteristics of CME activities was too small and the studies too heterogeneous to determine if any of these are crucial for CME success. Evidence was limited on the reliability and validity of the tools that have been used to assess CME effectiveness. Based on previous reviews, the evidence indicates that simulation methods in medical education are effective in the dissemination of psychomotor and procedural skills. Conclusions Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors and clinical outcomes. More research is needed to determine with any degree of certainty which types of media, techniques, and exposure volumes as well as what internal and external audience characteristics are associated with improvements in outcomes.

Effectiveness of continuing medical education.

Importance Readmission rates are used as an indicator of the quality of care that patients receive during a hospital admission and after discharge. Objective To determine the prevalence of pediatric readmissions and the magnitude of variation in pediatric readmission rates across hospitals. Design, Setting, and Patients We analyzed 568 845 admissions at 72 children's hospitals between July 1, 2009, and June 30, 2010, in the National Association of Children's Hospitals and Related Institutions Case Mix Comparative data set. We estimated hierarchical regression models for 30-day readmission rates by hospital, accounting for age and Chronic Condition Indicators. Hospitals with adjusted readmission rates that were 1 SD above and below the mean were defined as having “high” and “low” rates, respectively. Main Outcome Measures Thirty-day unplanned readmissions following admission for any diagnosis and for the 10 admission diagnoses with the highest readmission prevalence. Planned readmissions were identified with procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. Results The 30-day unadjusted readmission rate for all hospitalized children was 6.5% (n = 36 734). Adjusted rates were 28.6% greater in hospitals with high vs low readmission rates (7.2% [95% CI, 7.1%-7.2%] vs 5.6% [95% CI, 5.6%-5.6%]). For the 10 admission diagnoses with the highest readmission prevalence, the adjusted rates were 17.0% to 66.0% greater in hospitals with high vs low readmission rates. For example, sickle cell rates were 20.1% (95% CI, 20.0%-20.3%) vs 12.7% (95% CI, 12.6%-12.8%) in high vs low hospitals, respectively. Conclusions and Relevance Among patients admitted to acute care pediatric hospitals, the rate of unplanned readmissions at 30 days was 6.5%. There was significant variability in readmission rates across conditions and hospitals. These data may be useful for hospitals' quality improvement efforts.

https://jamanetwork.com/journals/jama/articlepdf/1558279/joc120138_372_380.pdf

Pediatric readmission prevalence and variability across hospitals

Excessive school absence disrupts learning and is a strong predictor of premature school dropout. School-aged children with asthma are absent more often compared to their healthy peers without asthma; yet, the causes are inadequately documented. We sought to determine the difference in mean absence days between children with and without asthma, the relationship between asthma severity and missed days from school, and if incident absences were due to asthma in a predominantly African American urban school district in the Midwestern United States. A cross-sectional analysis was conducted of 9014 students (grades K-12) followed for absenteeism over the 2002-2003 academic year. A subset of 543 students with asthma was assessed for asthma severity and cause of absence. Those with asthma (9.7% of students) were absent (mean = 9.2 days) approximately 1.5 more days compared to those without asthma (mean = 7.9 days) (p = .006). In the analysis comparing asthma severity and absenteeism, after adjusting for demographic variables and enrollment time, mean days absent increased with increasing asthma severity level: mild intermittent (mean = 8.5 days), mild persistent (mean = 11.3 days), moderate persistent (mean = 10.3 days), and severe persistent (mean = 11.6 days) (p = .001). Out of 1537 tracked absences that resulted from illness, 478 (31%) were due specifically to asthma-related symptoms. Children with asthma are absent from school more often compared to their healthy peers and this appears to be driven by the underlying severity of symptoms. (J Sch Health. 2006;76(1):18-24).

Asthma Status and Severity Affects Missed School Days

Background: Children with asthma experience more absenteeism from school compared with their nonasthma peers. Excessive absenteeism is related to lower student grades, psychological, social, and educational adjustment. Less is known about the relationship between the presence of asthma and the academic achievement in school-aged children. Since students with asthma miss more days from school, this may negatively impact their academic achievement. The goal of this study was to investigate the relationships between absenteeism, presence of asthma, and asthma severity level with standardized test level performance in a predominantly African American urban school district.

Methods:  A cross-sectional analysis was conducted of 3812 students (aged 8-17 years) who took the Missouri Assessment Program (MAP) standardized test during the 2002-2003 academic year.

Results:  After adjustment for covariates, a significant inverse relationship was found between absenteeism and test level performance on the MAP standardized test in all children (F = 203.9, p < .001). There was no overall difference in test level achievement between those with and without asthma (p = .12). Though not statistically different, those with persistent asthma showed a modestly increased likelihood of scoring below Nearing Proficient compared with those with mild intermittent asthma (adjusted odds ratio = 1.93, 95% confidence intervals = 0.93-4.01, p = .08).

Conclusions:  A negative impact of absenteeism on standardized test level achievement was demonstrated in children from an urban African American school district. Children with asthma perform the same academically as their nonasthma peers. However, those with persistent asthma show a trend of performing worse on MAP standardized test scores and have more absence days compared with other students. More research is warranted on the effects of persistent asthma on academic achievement.

The Relationship Between School Absence, Academic Performance, and Asthma Status

The largest portion of the cost for asthma healthcare is due to hospitalizations. Improved methods of healthcare delivery for patients with asthma are needed to prevent readmissions. From 1996 to 1999, 96 adult subjects (predominantly young African American women) hospitalized with an asthma exacerbation, who had a history of frequent healthcare use, were randomized to an asthma nurse specialist intervention (n = 50) or a usual care group (n = 46) for 6 months. Our aim was to decrease rates of readmissions within 6 months of hospital discharge, to reduce cost, and to improve health-related quality of life. Our results demonstrate a 60% reduction in total hospitalizations (31 readmissions in the intervention group and 71 in the control group, p = 0.04), with no significant change in emergency department visits. Readmissions for asthma were reduced by 54% (21 vs. 42 in the control group; p = 0.04). We found a marked reduction in lost work or school days: 246 versus 1040 days in the control group (p = 0.02). The intervention resulted in a substantial reduction in direct and indirect healthcare costs, saving US dollars 6462 per patient (p = 0.03). A brief intervention program focusing on high healthcare users with asthma can result in improved asthma control and reduced hospital use with substantial cost savings.

https://www.atsjournals.org/doi/pdf/10.1164/rccm.200208-877OC

Asthma Intervention Program Prevents Readmissions in High Healthcare Users

Asthma guidelines, established by the National Asthma Education and Prevention Panel (NAEPP), seek to guide physicians in the appropriate assessment and treatment of asthma. Poor physician adherence to these guidelines has been documented because of a variety of reported barriers. We sought to test the efficacy of the Community Asthma Program (CAP), which was designed to help primary care physicians (PCP) assess asthma severity and to prescribe medications according to NAEPP guidelines. A prospective, observational study was conducted in 723 patients with asthma (aged < 1–85 years) in two primary care clinics. PCPs had access to patient responses to asthma symptom questions at each visit. The correlations between patient self-reported and PCP-classified asthma severity, treatment prescribed, and missed days from work or school were determined. The effect of the intervention on guideline adherence was assessed by asthma severity level and time. An overall moderate measure of agreement was found between pat...

Sue Crocker

Papers

Asthma Intervention Program Prevents Readmissions in High Healthcare Users

Community Asthma Program improves appropriate prescribing in moderate to severe asthma.