The Science Journal of the American Association for Respiratory Care

1999 OPEN FORUM Abstracts

CAN MODIFIED ACADEMIC DETAILING IMPROVE HOMEGOING MEDICATION PRESCRIBING FOR HOSPITALIZED ASTHMATICS?

Timothy R. Myers BS, RRT, Carolyn Kercsmar MD, Robert Chatburn RRT. Case Western Reserve University and Rainbow Babies & Childrens Hospital, Cleveland, OH.

History: Hospital admission for acute asthma constitutes a major treatment failure. Although there are multiple causes for severe asthma exacerbations, prescribing inadequate medications based on level of chronic disease severity may be a significant contributing factor. The revised asthma guidelines published by the NAEPP/NIH in 1997 stressed the importance in prescribing medications based on disease severity. Aim: Determine if asthma patients' medications are appropriate for chronic disease severity on admission to our pediatric hospital, and employ a modified academic detailing model to improve discharge prescriptions.

Methods: As part of our asthma disease management program, we obtain a standardized admission history that includes information on patients' recent symptoms, prescribed medications, daily activity impairment and health care utilization. From this data, we are able to determine a chronic asthma severity class based on NIH guidelines. All patients are evaluated as mild intermittent (MI), mild persistent (MIP), moderate persistent (MOP), severe persistent (SP), and severe life threatening (SLT). A pediatric pulmonologist suggests homegoing medications for each patient based on this disease severity data. Shortly after hospital admission, these severity-based recommendations are placed in each patient's chart for their primary care physicians (PCP) or facility-based attending. We compared chronic medications at admission vs. those prescribed at discharge.

Results: Complete data was reviewed for 241 patients. Breakdown by severity class: MI = 47, MIP = 86, MOP = 75, Sp = 29, SLT = 4. On admission, 74% of patients had inappropriate chronic medications by disease severity according to NIH/NAEPP guidelines. Underprescribing increased with disease severity (MI-45%, MIP-72%, MOP-85%, SP-97%, SLT-100%). With this intervention available to PCPs prior to discharge, 82% of the patients had medication upgrades to match severity. The lowest increase was found in patients with MOP (72%). All severity classes had significant (p<. 05) upgrades in medications at discharge. Albuterol as the only routine medication prescribed decreased from 53.9% to 17.4%. Prescribing cromolyn and/or inhaled steroids increased in both MIP (29% - 85%) & MOP (71% - 95%) severity classes.

Table 1. Medications by Severity Class on Admission (%)

Alb. Only Alb/Intal Alb/ICS Alb/Intal/ICS Alb/ICS/other
MI 95.7 4.3 0 0 0
MIP 69.8 26.7 2.3 1.2 0
MOP 28 56 12 4 0
SP 13.8 62.1 17.2 6.9 0
SLT 0 75 0 0 25

Table 2. Medications by Severity Class at Discharge (%)

Alb. Only Alb/Intal Alb/ICS Alb/Intal/ICS Alb/ICS/other p value
MI 57.4 36.2 0 6.4 0 <0.001
MIP 14 62.8 16.3 5.8 1.1 <0.001
MOP 4 48 32 6.7 9.7 <0.001
SP 0 17.2 51.7 3.4 28.4 <0.001
SLT 0 0 0 0 4 <0.029

Conclusions: A modified academic detailing model can improve chronic medication regimens of pediatric asthmatics that are hospitalized. Further long-term

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