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The Effect of Easy Breathing on Asthma Management and Knowledge
Michelle M. Cloutier, MD;
Dorothy B. Wakefield, MS;
Penelope S. Carlisle, MSN;
Howard L. Bailit, DMD, PhD;
Charles B. Hall, PhD
Arch Pediatr Adolesc Med. 2002;156:1045-1051.
ABSTRACT
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Objective To determine whether Easy Breathing, an asthma management program, improves
adherence to national asthma guidelines.
Design Before and after intervention trial.
Setting Six urban primary care clinics in Hartford, Conn.
Participants Thirty-four primary care physicians, 37 midlevel practitioners, 32 nurses,
and 69 pediatric and family practice residents and medical students.
Interventions Knowledge was assessed before (pretest) and after (posttest) a training
program and 12 to 18 months after (follow-up) implementing Easy Breathing.
Questions were divided into factual, guideline recommendation, and guideline
application.
Main Outcome Measures The percentage of correct responses on the pretest, posttest, and follow-up
tests; clinician adherence to national guidelines; and clinician attitudes.
Results The percentage of correct responses on the pretest was higher for physicians
(mean, 61%; 95% confidence interval [CI], 57%-65%) than for midlevel practitioners
(mean, 54%; 95% CI, 50%-59%) (P= .01). Correct responses
increased significantly on the posttest for physicians (mean, 77%; 95% CI,
74%-81%) in all 3 subgroups of questions (P<.001)
and for midlevel practitioners (mean, 69%; 95% CI, 63%-75%) overall and for
factual and guideline questions. On the follow-up test, improvements in factual
and guideline responses disappeared for all clinicians but were sustained
for applied questions (mean, 78% [95% CI, 63%-94%] for physicians and 65%
[95% CI, 51%-78%] for midlevel practitioners). Adherence to prescribing guidelines
after implementing Easy Breathing was 93% to 99% and was associated with a
3-fold increase in inhaled corticosteroid prescriptions. Physicians reported
that they had integrated Easy Breathing into practice but did not think this
represented a substantial change.
Conclusions Easy Breathing increases clinicians' knowledge and use of national guidelines.
Primary care physicians believe they are adhering to guidelines even when
they are not.
INTRODUCTION
ASTHMA IS the most common chronic disease of children. Despite effective,
available treatments, asthma is associated with high morbidity and significant
mortality.1-2 Reducing asthma
morbidity is a national health care objective, and to this end, the National
Heart, Lung, and Blood Institute published consensus treatment guidelines
in 1990 and 1997.3-4 The National
Asthma Education and Prevention Program (NAEPP) guidelines recommend first-line
use of anti-inflammatory drugs to reduce the airway inflammation and hyperresponsiveness
that underlie chronic asthma and use of ß-adrenergic agonists as "rescue"
medications. Despite the wide dissemination of these guidelines, anti-inflammatory
drugs are underprescribed.5-12
Factors associated with underprescribing include deficiencies in clinician
knowledge, lack of self-efficacy and outcome expectancy, concerns regarding
the safety of inhaled corticosteroids in children, and confusion regarding
how to implement the guidelines in practice.12-15
Easy Breathing, a copyrighted asthma management program for primary
care clinicians, was developed in 1998. The goals of Easy Breathing are to
improve the diagnosis, determination of disease severity, and treatment of
asthma for disadvantaged, urban, primarily minority children. In this article,
we describe the effect of Easy Breathing on clinician knowledge, adherence
to asthma guidelines, and attitudes.
METHODS
Easy Breathing is an asthma management program for clinicians who care
for children who reside or receive their medical care in Hartford, Conn.16 Eighty-four percent of the children in Hartford are
eligible for medical assistance, which is now administered entirely through
managed care programs. Elements of the program have been previously described.16-17 The program was designed for busy
primary care physicians who work in clinic settings with a high volume of
patients. (It is available free of charge to qualified health care clinicians
via an e-mail request to Dr Cloutier.) The program consists of a validated
survey that is completed by the parents of all children (6 months to 18 years
of age) who present for care, for any reason, at any of the 6 primary care
clinics in Hartford.17 The survey has been
previously described17 and consists of 4 questions
related to asthma symptoms, 6 questions about triggers for symptoms, previous
diagnosis of and treatment for asthma, and family history, and 8 demographic
and environmental exposure questions. The Easy Breathing program and its educational
components have been approved by the Institutional Review Board of Connecticut
Children's Medical Center. Children are diagnosed as having asthma by their
primary care physician, who reviews their responses to the survey questions
and their medical record and obtains additional history and testing as needed.
Physicians consider a diagnosis of asthma when children report recurrent (>2)
episodes of wheezing, cough, and/or shortness of breath in response to known
asthma triggers, and when other diseases have been excluded. For children
who are diagnosed as having asthma, asthma severity is determined by the physician
with the aid of a separate written instrument. The asthma severity instrument
consists of 6 questions about the frequency of daytime and nocturnal symptoms,
exercise impairment, and frequency of emergency department visits, hospitalizations,
intensive care unit admissions, and school absenteeism for asthma. For each
child with asthma, a comprehensive management plan consisting of a daily sick
and emergency treatment plan is developed using a severity-specific treatment
selection guide and color-coded (by severity) peel-away labels. The medication
labels are placed on a standardized, field-tested, written asthma treatment
plan that tells the parent what medications to use daily, when to use the
sick plan, what medications to use, and whom and when to call.18
Physicians can also prescribe asthma therapies not listed in the treatment
selection guide. All aspects of Easy Breathing, however, are in compliance
with the NAEPP asthma guidelines.
Before implementing Easy Breathing, clinicians at each site participated
in 4 hours of training. Approximately 90 minutes of each training session
was spent on how to use the Easy Breathing forms. The remainder of the time
was spent discussing asthma demographics, pathophysiology, and medications
and rationale for the recommendations for asthma management as outlined in
the NAEPP guidelines. A pediatric pulmonologist (M.M.C. and others) was available
for on-site consultation and assistance on an initially weekly and now as-needed
basis. The program is ongoing.
All physicians and midlevel practitioners (advanced practice nurses,
pediatric nurse practitioners, and physician assistants) completed a 50-question
pretest before the training session. All participants then received a 50-question
posttest approximately 2 to 4 weeks after the training and a 30-question follow-up
test 12 to 18 months after completion of the training session. Ten questions
were repeated on the pretest, posttest, and follow-up test. Questions were
divided into 3 categories. Factual questions dealt with symptoms of asthma,
triggers for asthma, and asthma epidemiology. Guideline recommendation questions
dealt specifically with NAEPP guideline recommendations, such as who should
have a flu shot, pulmonary function testing, and/or an allergy evaluation.
Guideline application or applied questions used clinical vignettes to determine
whether clinicians could determine asthma severity based on patient symptoms
and choose appropriate asthma therapy. These questions also determined whether
the clinician knew when and how to step up (increase) and step down (decrease)
therapy. Sample questions are shown in Table 1. The tests were based in part on a previous asthma instrument
that was modified and adapted for children.15
A panel of 4 specialists and 3 generalists reviewed all of the questions for
clarity and consistency with the NAEPP guidelines. Questions in which there
was disagreement were discussed using a modified Delphi approach and discarded
or rewritten and retested.
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Table 1. Examples of Questions on Pretest, Posttest, and Follow-up
Tests*
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Clinician adherence to NAEPP guidelines was determined by comparing
patient treatment plans with the severity-specific treatment selection guide.
As a further indication of adherence to treatment guidelines, information
regarding the number and type of prescription refills for asthma medications
were obtained for the year before beginning Easy Breathing and for the year
after instituting Easy Breathing for children covered by all Medicaid managed
care organizations. Clinical and utilization data were merged by a third party,
identification information was encrypted, and the data were returned to the
investigators for analysis.
Clinician attitudes toward Easy Breathing were investigated using a
Provider Satisfaction Survey that was distributed to all clinicians 12 to
18 months after program implementation. The survey used a Likert scale (1,
strongly agree, to 5, strongly disagree, with 3 indicating neither agree nor
disagree) and focused on the effect of Easy Breathing on knowledge, self-efficacy
(whether one can implement Easy Breathing), outcome expectancy (whether implementing
Easy Breathing will improve asthma management and medical service utilization),
and agreement with the guidelines.
For each of the 3 tests (pretest, posttest, and follow-up), both 2-sample t tests and Wilcoxon rank sum tests were used to compare
the differences between physicians and midlevel practitioners. Overall scores
and scores by question type (factual, guideline, and applied) were compared
this way.
For physicians and midlevel practitioners, both paired t tests and Wilcoxon signed rank tests were used to compare change
(pretest vs posttest, posttest vs follow-up, and so on) in overall scores
and scores by question type.
RESULTS
Medical care for 73% of the Medicaid population in Hartford is provided
in 6 primary care clinics. All clinics and all practitioners at the sites
agreed to participate in the Easy Breathing program. Training began June 1,
1998, and was completed December 31, 1998. Thirty-four physicians, 37 midlevel
practitioners, 32 nurses, and 69 pediatric and family practice residents and
medical students participated in the Easy Breathing program.
The number of clinicians who completed the pretest and posttest is shown
in Table 2. The overall response
rate for the posttest was 65%, a response rate similar to what others have
reported.15, 19
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Table 2. Response Rates for Practitioners for Pretest, Posttest, and
Follow-up Tests
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Mean test scores on the pretest were higher for physicians than for
midlevel practitioners (P = .01). Test scores increased
for both groups on the posttest. The mean correct score for all physicians
on the pretest was 61% (95% confidence interval [CI], 57%-65%) and increased
on the posttest to 77% (95% CI, 74%-81%) (P<.001).
The mean correct percentage score for all midlevel practitioners on the pretest
was 54% (95% CI, 50%-59%) and increased on the posttest to 69% (95% CI, 63%-75%)
(P<.001). Scores listed by question subgroups
are shown in Table 3. There was
no difference in pretest subgroup scores for physicians compared with midlevel
practitioners. Significant increases in the percentage of correct responses
were noted on the posttest for physicians in all question subgroups, with
the greatest improvement in responses to applied questions. Subgroup scores
for factual and guideline questions increased for midlevel practitioners on
the posttest; scores for applied questions were not significantly changed.
On the posttest, physicians demonstrated a greater number of correct responses
on applied questions compared with midlevel practitioners (P = .01). In the 12 to 18 months after implementing Easy Breathing,
there was a 34% decrease in the number of primary care clinicians in Hartford
secondary to a financial crisis caused by low reimbursement rates. Of potential
respondents, the response rate for the follow-up test was 46%. Respondents
were not different from nonrespondents in their overall scores or in the individual
subgroup scores for either physicians or midlevel practitioners (P = .21). The mean percentage of correct responses for the follow-up
test was 68% (95% CI, 60%-76%) for physicians and 59% (95% CI, 49%-69%) for
midlevel practitioners. The differences in mean scores on the pretest and
follow-up test were not statistically significant (physicians: P = .72; midlevel practitioners: P = .76).
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Table 3. Correct Responses by Different Groups of Clinicians to Categories
of Questions on the Pretest, Posttest, and Follow-up Test*
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Improvements in factual and guideline knowledge observed on the posttest
were not sustained on the follow-up test. The mean scores for factual and
guideline questions between the pretest and the follow-up test were not significantly
different. The improvements made in the applied questions on the posttest
were maintained by physicians (P = .04), whereas
midlevel practitioners showed further improvements on the follow-up test compared
with the posttest (P = .01). There was no difference
in the pretest results for clinicians who completed the posttest and follow-up
test and those who did not.
GUIDELINE ADHERENCE
Clinician adherence to the NAEPP guidelines was determined by examining
the specific therapy prescribed by the clinicians. Using initial asthma severity,
overall clinician adherence to NAEPP prescribing guidelines ranged from 93%
for moderate, persistent asthma to 99% for mild, persistent asthma. The lower
rate of adherence to NAEPP prescribing guidelines for children with moderate,
persistent asthma was due to use of leukotriene modifiers by some clinicians,
which is currently not recommended in the NAEPP guidelines for asthma of this
severity, but it is of potential benefit based on recent literature.4, 20 When this therapy was excluded from
the analysis, overall adherence to guidelines for inhaled corticosteroids
was 98% to 99%. Clinician adherence to the NAEPP guidelines has not changed
during the first 2 years, except for the use of leukotriene modifiers for
children with moderate, persistent asthma, which has increased with time.
Another marker of NAEPP guideline adherence that was examined was referral
to a subspecialist. Subspecialty referral for children with severe, persistent
asthma was 58% in 1998 and was 70% in 2000.
Paid medication claims for asthma prescription drugs for the 860 children
with asthma enrolled in Easy Breathing between June 1, 1998, and December
31, 1998, were examined for the 12-month period before implementing Easy Breathing
(July 1, 1997, to June 30, 1998) and for the 12-month period after enrollment
(January 1 to December 31, 1999) (Table
4). In these analyses, asthma severity at the time of enrollment
in the Easy Breathing program was used. Inhaled steroidal and nonsteroidal
anti-inflammatory therapy increased with increasing asthma severity before
implementation of Easy Breathing. In contrast, after implementing Easy Breathing,
children with mild asthma received more nonsteroidal inhaled anti-inflammatory
drugs than children with moderate or severe asthma (P
= .01). In addition, there was a marked increase in inhaled corticosteroid
therapy with increased severity (P = .01). This pattern
is in keeping with the NAEPP guidelines that recommend nonsteroidal anti-inflammatory
therapy only in children with mild, persistent asthma. Overall, there was
a 3-fold increase in prescribed inhaled corticosteroid therapy after implementing
Easy Breathing. The increase in inhaled corticosteroid therapy was also associated
with a decrease in oral corticosteroid therapy for asthma of all severities
(Table 4).
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Table 4. Prescription Drugs for Asthma by Asthma Severity for Children
Before (1997-1998) and After (1999) Enrollment in Easy Breathing*
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CLINICIAN ATTITUDES
All clinicians thought that the Easy Breathing training curriculum had
increased their knowledge of asthma and the Easy Breathing program (Table 5). All clinicians felt positively
toward the program, but for all other areas of the Easy Breathing program,
midlevel practitioners were consistently more enthusiastic than physicians.
Midlevel practitioners thought that Easy Breathing had significantly improved
their ability to diagnose asthma, whereas physicians were less convinced.
This was despite the observation that 18% of the children with asthma were
newly diagnosed as having asthma through the program. Both physicians and
midlevel practitioners did not believe strongly that Easy Breathing had replaced
their former asthma management practice model.
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Table 5. Clinician Attitudes
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COMMENT
Despite our increased understanding of the pathophysiology of asthma
and the release and dissemination of national guidelines for the management
of asthma, clinician knowledge about asthma and use of guidelines remains
low.5-12
Studies have shown that only 11% to 66% of patients with persistent asthma
are prescribed inhaled corticosteroids,5, 11
only 27% of patients with severe asthma are referred to specialists,11 and only 50% of patients are given a written treatment
plan.10 All of these activities are recommended
in the 1997 NAEPP guidelines. Barriers to clinician adherence to practice
guidelines in relation to behavior change theory include knowledge (lack of
awareness or lack of familiarity), attitudes (lack of agreement, lack of self-efficacy,
lack of outcome expectancy, or the inertia of previous practice), or external
barriers (eg, patient factors, lack of time or resources, or organizational
constraints).12 Interventions that have been
used to overcome these barriers have had variable success in part because
they address a limited number of barriers and in part because they fail to
consider the social and organizational context in which the clinician works.22-30
In this study, we examined the effect of a guideline-based educational program
as part of an asthma management program on clinician behavior.
In our study, baseline clinician knowledge about asthma was low but
similar to results reported by others.15, 19
Although improvements in knowledge were found immediately after an intensive
educational program, these improvements were not sustained. Educational programs,
including continuing medical education courses and local programs, have not
been effective in changing clinician behavior when used alone.25
With Easy Breathing, clinicians are guided to determine asthma severity, treatment,
and adequacy of asthma control for every child with asthma in their practice.
We believe that the daily, consistent repetition of this approach is the major
strength of the Easy Breathing program and is the reason why improvements
in asthma management (applied questions) have been sustained 1 year after
program implementation. Whether such improvements would be sustained if the
program were withdrawn is unknown, but based on other studies, we believe
that it is unlikely.31 Easy Breathing has not,
however, changed all elements of clinician adherence. The program has increased
the number of patients with severe, persistent asthma who were referred to
a specialist, but adherence to this element of the guidelines is not as high
as that for anti-inflammatory drug use.
We did not have a control group. Thus, it is possible that general changes
in clinician knowledge may have occurred during this 18-month program. We
think this is unlikely since clinician behavior in using the guidelines has
not significantly changed since their release in 1991.5, 7-11
Easy Breathing was directly modeled after the NAEPP guidelines. This
close adherence to the NAEPP guidelines and the support for the guidelines
by the pediatric pulmonary specialists in the community markedly reduced the
"disagreements" about asthma management by clinicians. In addition, the flexibility
of the program that allowed clinicians to choose asthma therapy dispelled
concerns about rigidity and challenges to autonomy in patient management.
Feedback to clinicians, including specific clinician and clinic feedback,
along with subspecialty availability, has reinforced this approach.
Previous studies have, in general, used either responses to clinical
vignettes or prescribing behaviors as indicators of adherence to guidelines.
Responses to surveys do not always correlate with actual practice behaviors.32 Results from other studies5, 10-11
suggest that clinicians are more likely to use inhaled corticosteroids in
clinical vignettes than in their actual prescribing behavior. For this reason,
we used prescribing patterns and pharmacy prescriptions as further evidence
of a change in behavior. Before Easy Breathing, only 18% of children with
asthma in Hartford received a prescription for an inhaled anti-inflammatory
drug. After implementation of Easy Breathing, there was a significant increase
in prescriptions for inhaled corticosteroids overall with appropriate use
according to asthma severity. Bronchodilator use was unchanged, whereas oral
corticosteroid therapy decreased. Although other aspects of medical services
utilization are currently being examined, underuse of anti-inflammatory drugs
has been associated with greater risk of fatal and near-fatal asthma and increased
rates of hospitalization.11, 33-34
Primary care clinicians readily accepted Easy Breathing into their practice.
Clinicians particularly liked the asthma treatment guide that gave them a
broad selection of potential appropriate therapies. Despite the ease of use,
however, clinicians still expressed concerns about the length of time that
managing this chronic disease imposed on their already busy schedules. The
decline in the number of clinicians in Hartford has further heightened these
issues. Nevertheless, adherence to prescribing guidelines is greater than
93%, with increased inhaled corticosteroid therapy and decreased oral corticosteroid
use, suggesting fewer asthma exacerbations. Despite the significant changes
in inhaled corticosteroid use in the community, clinicians did not believe
that Easy Breathing had substantially changed their prescribing patterns.
Clinicians believed that they were implementing appropriate asthma care before
Easy Breathing began, and Easy Breathing has not changed this perception.
This observation could explain in part why educational programs, such as continuing
medical education courses, have not been effective in changing clinician behavior
regarding asthma treatment. If clinicians think they are already using corticosteroids
in their practice, they will not be motivated by continuing medical education
courses to change their behavior.
In summary, the Easy Breathing program improved primary care clinician
adherence to asthma guidelines, increased inhaled corticosteroid therapy,
and decreased the need for oral corticosteroids in an urban community with
a high prevalence of poverty and asthma. Studies using the program in other
communities and in private practice settings are currently under way.
| What This Study Adds
Despite the wide dissemination of asthma guidelines, anti-inflammatory
drugs are underprescribed. Factors associated with underprescribing include
deficiencies in knowledge, lack of self-efficacy and outcome expectancy, concerns
regarding the safety of inhaled corticosteroids in children, and confusion
regarding how to implement the guidelines in practice. In this article, we
describe the effect of an asthma management program, called Easy Breathing,
on clinician knowledge, adherence to asthma guidelines, and attitudes. We
demonstrate that use of an asthma management program can improve clinician
adherence to guidelines and increase anti-inflammatory therapy. We also demonstrate
that Easy Breathing increases clinicians' knowledge and use of national guidelines.
Primary care physicians believe they are adhering to guidelines, even when
they are not, which may explain, in part, why continuing medical education
courses have been insufficiently ineffective in changing clinician behavior.
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AUTHOR INFORMATION
Accepted for publication June 6, 2002.
The financial support and personal encouragement by the trustees and
staff of the Donaghue Medical Research Foundation, West Hartford, Conn, are
very much appreciated.
Presented in part at the American Thoracic Society International Conference,
San Francisco, Calif, May 20, 2001.
We thank the clinicians and office staff of Asylum Hill Family Practice
Center, Burgdorf/Fleet Health Center, Community Health Services, Family Health
Center, St Francis Hospital/Pediatrics Ambulatory Care, and Connecticut Children's
Medical Center/Primary Care Center, all in Hartford, Conn, for their dedication
to patient care and their willingness to participate in the Easy Breathing
program. Special thanks to Karen L. Daigle, MD, and Craig D. Lapin, MD, for
their work with the Easy Breathing sites and Krissy Larrow for administrative
support.
Easy Breathing is available from the author (Dr Cloutier).
Corresponding author and reprints: Michelle M. Cloutier, MD, Connecticut
Children's Medical Center, 282 Washington St, Hartford, CT 06106 (e-mail: mclouti{at}ccmckids.org).
From the Pulmonary Division, Department of Pediatrics (Dr Cloutier
and Ms Carlisle), Department of Community Medicine and Health Care (Ms Wakefield),
Health Policy Center (Dr Bailit), University of Connecticut Health Center
(Drs Cloutier and Bailit, and Mss Wakefield and Carlisle), Connecticut Children's
Medical Center (Dr Cloutier), Hartford; and Department of Epidemiology and
Social Medicine, Albert Einstein College of Medicine of Yeshiva University,
Bronx, NY (Dr Hall).
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ABSTRACT
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