Self-reported physician practices for children with asthma: Are national guidelines followed?

Objective. To determine self-reported adherence to national asthma guidelin es for children by primary care physicians in managed care; and, to analyze sources of variation in these practices by physician specialty and managed care practice type. Design. A survey of 671 primary care physicians (pediatricians and family p hysicians) practicing in 3 geographically diverse managed care organization s (MCO). Domains of interest included asthma diagnosis, pharmacotherapy, pa tient education and follow-up, and indications for specialty referral. Item formats included self-reports of usual practice and responses to case vign ettes. Results. A total of 429 (64%) physicians returned surveys, 22 of whom did n ot meet criteria for inclusion in the analysis. Most respondents had both h eard of (91%) and read (72%) the National Asthma Education and Prevention P rogram (NAEPP) guidelines. For diagnosis, 75% reported routine use of offic e peak flow measurement, but only 21% used spirometry routinely. Family phy sicians were more likely than pediatricians to use spirometry in diagnosis (odds ratio [OR] = 5.9), and less likely to recommend daily peak flow measu rement (OR = .3). The median reported frequency of providing written care p lans was only 50%. Though inhaled corticosteroids were deemed very safe or safe by 93%, almost half had specific concerns regarding at least 1 side ef fect, most commonly growth delay. Primary care physicians' criteria for ref erral to an asthma specialist differed from those of the NAEPP panel in cho osing to manage more severe patients without asthma specialist input. Famil y physicians were more likely than pediatricians to refer a child after a s ingle hospitalization, 2 to 3 emergency department visits, after 2 exacerba tions, or if the child was <3 years old and required daily medications. Res ponses to vignettes showed generally appropriate initial use of antiinflamm atory agents, but reluctance to increase the dose in response to continued symptoms, and less frequent follow-up than recommended by the NAEPP. Conclusion. Most physicians for children report having read and adopted NAE PP guideline recommendations for asthma treatment, including generally appr opriate use of medications. Opportunities for improvement exist in specific areas such as the use of written care plans, optimizing antiinflammatory d osing, and providing routine follow-up. Although physicians show evidence o f awareness of national guidelines and knowledge consistent with much of th eir content, additional work is required to promote the use of self-managem ent tools in practice.