The Science Journal of the American Association for Respiratory Care
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 (%)
Table 2. Medications by Severity Class at Discharge (%)
|Alb. Only||Alb/Intal||Alb/ICS||Alb/Intal/ICS||Alb/ICS/other||p value|
Conclusions: A modified academic detailing model can improve chronic medication regimens of pediatric asthmatics that are hospitalized. Further long-term