Patient factors used by pediatricians to assign asthma treatment

Abstract

Objective: Although asthma is often inappropriately treated in children, little is known about what information pediatricians use to adjust asthma therapy. The purpose of this work was to assess the importance of various dimensions of patient asthma status as the basis of pediatrician treatment decisions.

Patients and methods: We conducted a cross-sectional, random-sample survey, between November 2005 and May 2006, of 500 members of the American Academy of Pediatrics using standardized case vignettes. Vignettes varied in regard to (1) acute health care use (hospitalized 6 months ago), (2) bother (parent bothered by the child's asthma status), (3) control (frequency of symptoms and albuterol use), (4) direction (qualitative change in symptoms), and (5) wheezing during physical examination. Our primary outcome was the proportion of pediatricians who would adjust treatment in the presence or absence of these 5 factors.

Results: Physicians used multiple dimensions of asthma status other than symptoms to determine treatment. Pediatricians were significantly more likely to increase treatment for a recently hospitalized patient (45% vs 18%), a bothered parent (67% vs 18%), poorly controlled symptoms (4-5 times per week; 100% vs 18%), or if there was wheezing on examination (45% vs 18%) compared with patients who only had well-controlled symptoms. Pediatricians were significantly less likely to decrease treatment for a child with well-controlled symptoms and recent hospitalization (28%), parents who reported being bothered (43%), or a child whose symptoms had worsened since the last doctor visit (10%) compared with children with well-controlled symptoms alone.

Conclusions: Pediatricians treat asthma on the basis of multiple dimensions of asthma status, including hospitalization, bother, symptom frequency, direction, and wheezing but use these factors differently to increase and decrease treatment. Tools that systematically assess multiple dimensions of asthma may be useful to help further improve pediatric asthma care.

FIGURE 1

The impact of acute care, bother, control, direction, and wheeze on the tendency of pediatricians to step up treatment under each studied vignette. In each case, the patient was one who was already receiving low-dose ICS. The first bar represents the proportion of pediatricians who would step up treatment for patients with mild intermittent symptoms (1 time in past 2 weeks). In this case, 18% of pediatricians would step up therapy. The other bars represent the proportion of pediatricians who would step up treatment of patients with only 1 key factor changed (acute care, direction, bother, wheeze, or control; persistent symptoms 4–5 times per week). Each studied factor significantly increased the propensity to step up treatment. For example, the second bar represents the case of symptoms 1 time in the past 2 weeks, as well as history of acute care (hospitalization 6 months ago). In this case, pediatricians were significantly more likely to step up treatment than if they had had no acute care visits (45% of pediatricians; P <.001). Sx indicates symptoms.

FIGURE 2

The impact of acute care, bother, control, and direction on the tendency of pediatricians to step down treatment under each studied vignette (no pediatricians recommended decreasing treatment for a patient with a history of acute care, worse symptoms, and parents who were bothered by the child’s asthma). In each case, the patient was one who was already receiving high-dose ICS, LABA, and LTM for the past 6 months. The first bar represents the proportion of pediatricians who would step down treatment of patients with mild intermittent symptoms (1 time in past 2 weeks). In this case, 60% of pediatricians would step down therapy. The other bars represent the proportion of pediatricians who would step down treatment with only 1 key factor changed (acute care, direction, and bother). Each studied factor significantly decreased the propensity to step down treatment. For example, the second bar represents the case of symptoms 1 time in the past 2 weeks, as well as history of acute care (hospitalization 6 months ago). In this case, pediatricians were significantly less likely to step down treatment than if they had had no acute care visits (28% of pediatricians; P <.001). Sx indicates symptoms.