How do clinicians who treat asthma rate their own adherence to tenets of evidence-based guidelines? Lead authors on analyses of a national survey respond.
Effective asthma care is a complex process whether delivered in primary care, where 60% of asthma is treated, at the subspecialty level, or in the community clinic setting.
Clinical guidelines provide expert and evidence-based recommendations to help practicing clinicians navigate disease complexity and to individualize and optimize care for their patients. For all clinicians who treat asthma, those are The Guidelines for the Diagnosis and Management of Asthma 2007 (EPR-3).
At the recent American Academy of Asthma, Allergy, and Immunology virtual Annual Meeting, Drs Michelle Cloutier and Lara Akinbami presented results of their research on how clinicians across primary and specialty care feel about their own adherence to, and self efficacy to implement, the foundational principles of these guidelines. They talked to Patient Care Online about the results and their implications.
Michelle M Cloutier, MD, is Professor Emerita of Pediatrics and Medicine at the University of Connecticut School of Medicine and Director of the Asthma Center at Connecticut Children's Medical Center, in Storrs, CT. For 35 years she has been an NIH-funded researcher.
Capt Lara Akinbami, MD, is a medical officer and epidemiologist at the National Center for Health Statistics of the Centers for Disease Control and Prevention and a clinical pediatrician at the Walter Reed National Military Medical Center.
The following transcript has been lightly edited for clarity.
Patient Care Online: You are each co-authors of different analyses of data from 2012, from the National Asthma Survey of Physicians. Dr Cloutier lead an analysis in 2018, looking at the differences between primary care clinicians and asthma specialists and Dr Akinbami lead the more recent analysis, published in mid-2020 and also presented at AAAAI that looked at variations in adherence among different primary care groups: family medicine, internal medicine, pediatrics, and community health care clinicians. I'm going to ask Dr Akinbami to start first and highlight the findings for primary care in those 4 NAEPP cornerstone domains and talk a bit about where poor adherence or clinician lack of confidence was most apparent.
Lara Akinbami, MD: I think that's a very digestible way to approach the guidelines—to realize they might be 400 pages long, but there's really just 4 key elements.
The first is assessment and monitoring of asthma control and severity. So those are things like assessing severity to figure out how to initiate treatment, what level of treatment does the patient need. To assess control at each visit; make sure you know how well they're doing with control. Providing spirometry every 1 to 2 years to keep track of lung function and following up every 6 months, at least for patients with persistent asthma, and referral for specialist care for patients who need more intensive treatment.
And the second Cornerstone is patient education for self-management. So those are, for example, providing an asthma action plan which involves all the cornerstones in one place. But it's really a platform that you can come to agreement on with the family and patient on what's needed and do the education for recognizing symptoms, knowing which medications to give, when to give them, what the risk factors are that they need to avoid, and how they're administering their medications. So basically, assessing inhaler technique.
The third Cornerstone is environmental assessment. So that's assessing triggers for asthma, exacerbations that can occur in all settings home, school, and work. Identifying the patient-specific sensitivities that may involve allergy testing, or a lot of history taking, and advising patients and how to reduce their exposures to those things to which they’re sensitive.
The fourth Cornerstone is pharmacologic treatment or medication. Probably everyone is very familiar with those purple diagrams in the guidelines, which have the stepwise approaches of how to approach treatment. And those can be kind of daunting, but really, it's related to the first Cornerstone again, assessing where the patient is, and stepping up and stepping down medication, and realizing that inhaled corticosteroids are the most effective long-term control therapy and kind of a starter medication for patients who need that.
As you mentioned, to assess adherence for these 4 things we convened a federal workgroup, actually Dr Cloutier was the instigator of this; I don't know if she remembers that, it was ages ago. She said, “We really need to figure out what clinicians are doing. And, oh, CDC has a survey for that!” There were several agencies in the work group, we got the funding, and drafted this so that we would get a national sample; so rather than being confined to one healthcare system or a certain region of the country, we really did get a snapshot across the country, among primary care practitioners as well as asthma specialists.
So we asked about their agreement with the guidelines; about their self-efficacy, ie, how effectively did they think they can actually execute the recommendations, and about their adherence with the recommendations for each of these 4 domains. And what we found probably isn't all that surprising to anyone in primary care practice, is that clinicians are more likely to follow the recommendations that are easier to do like history taking or assessing impairment and risk. They're also very likely to use inhaled corticosteroids as the primary medication for long term control.
The sticky parts are probably already well recognized by people in the trenches. And those are recommendations they say they would be better able to follow “…if I have more time and training, expertise and resources.” So for example, spirometry uptake was low. And as a pediatrician, I can tell you how hard it is to find a spirometer in primary care practice. You really have to refer patients. And you have to get the patient buy-in for that as well.
Providing asthma action plans was also pretty low. And I guess that’s not surprising because there's a lot of difference in opinion of how useful they are. But I think that a lot of that outlook has to do with the perception that it’s just a piece of paper that you hand to the patient. But instead, if you really think of it (the asthma action plan) it is the cornerstone of all the elements of recommendations that you need to adhere to. So you need to actually assess the triggers, educate the patient on the symptoms, do all the history- taking, identify the medications and the doses and the frequency—put all that down on a piece of paper, have the patient buy in to that and then have that as a touchstone, as you go forward, paying attention to how much it needs to be adjusted or not. It is kind of what people (physicians) are doing all the time. And instead, it's kind of been boiled down to this piece of paper, which is a shame.
So I'm hoping maybe we could change the paradigm on that, because that is one of the places we found that was one of the more useful parts of the guidelines that have low uptake. I'm sure, Michelle, you have other things you want to talk about too. So I'll turn it over to you.
Michell Cloutier, MD: Okay, well, I think the one other thing that Lara didn't mention was checking inhaler technique. And this is an aspect of care that is not actually often used, as we found out, by either primary care clinicians or by specialists. And we know that inhalers are one of the mainstays of chronic asthma management. And patients don't always use their inhaler. And when they do use it, they don't always use it correctly. And we know that poor inhaler technique contributes to poor outcomes. And so one of the things that I think it's really important that we stress in the area of education and check on a frequent basis, is inhaler technique, which is problematic. So I think that's the only other thing, Lara, that I would add to your, to your list of, of issues.