INADEQUATE OUTPATIENT MEDICAL THERAPY FOR PATIENTS WITH ASTHMA ADMITTED TO 2 URBAN HOSPITALS

PURPOSE: To determine the patterns of chronic outpatient management in urban patients with moderate and severe asthma, and to assess medical practice adherence to the Guidelines for the Diagnosis and Management of Asthma from the National Asthma Education Program (NAEP). PATIENTS AND METHODS: This is a cross-sectional survey of adult patients with asthma admitted to the general medical services at the Johns Hopkins M edical Institutions (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center), Baltimore, Maryland. Subjects were 101 adults admitte d with an asthma exacerbation from February 1992 through January 1993. Using a validated questionnaire, these subjects were surveyed within 48 hours of admission concerning their chronic outpatient medical mana gement and the measures patients or their physicians took to alleviate symptoms during the asthma exacerbation leading to hospitalization. R ESULTS: The average asthma admission rate in the past year for this gr oup of patients was 2.5, indicative of moderate to severe disease. Les s than half of these patients had been prescribed inhaled anti-inflamm atory therapy. Of the patients who had previously been shown the meter ed dose inhaler technique by a health care professional, 11% could per form all components of this technique correctly. Only 28% of patients had been given an action plan by their physician in the event of an ac ute exacerbation. Sixty percent of patients who contacted their physic ian during the exacerbation that preceded admission had no changes mad e in their treatment regimen. In those whose exacerbation lasted at le ast 24 hours, the average beta-agonist metered dose inhaler use during the 24 hours prior to admission was 44.8 +/- 7.8 puffs (mean +/- stan dard error of the mean). Older age, current smoking, and race (black) were the most significant correlates of inhaled beta-agonist use durin g this period. CONCLUSIONS: This is the first documentation of the mul tiple problems in conforming with the standards of care delineated by the NAEP as they relate to the outpatient management of inner-city pat ients with moderate to severe asthma in the United States. In this pop ulation of patients with asthma, management was characterized by under utilization of anti-inflammatory therapy, inability to use inhalation devices properly, inadequate communication between patient and physici an of an action plan to be utilized in the event of an acute exacerbat ion, and inadequate physician intervention during the acute stages of the exacerbation. There was also overutilization of inhaled beta-agoni sts during exacerbations. It is imperative that these aspects of manag ement, for which the NAEP has set standards of care, are addressed as part of the effort to reduce asthma morbidity in the urban United Stat es.