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National Heart, Lung, and Blood Institute Guidelines and Asthma Management Practices Among Inner-City Pediatric Primary Care Providers^*

^* From the Department of Pediatrics (Drs. Rastogi, Shetty, and Harijith), Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx; and New York State Psychiatry Institute (Dr. Neugebauer), Columbia University, New York, NY.

Correspondence to: Deepa Rastogi, MD, Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY 10467; e-mail: dr271{at}hotmail.com

Abstract

Background and objective: Most surveys of pediatric outpatient asthma management obtain information from parents and caregivers. Studies based on surveys of primary health-care providers are sparse. Suboptimal outpatient management may play a role in the high hospitalization rates among inner-city asthmatic children. Asthma management practices were compared between hospital-based and community-based primary care providers (PCPs). Adherence to National Heart, Lung, and Blood Institute (NHLBI) guidelines was evaluated, along with practices not clearly defined in the guidelines such as use of oral cough medicines and albuterol suspension.

Design/methods: An 8-point questionnaire was administered to 48 community-based and 32 hospital-based PCPs practicing in inner-city neighborhoods. The questionnaire addressed three "positive" practices (classification of asthma severity, use of asthma action plan, and use of a spacer) and three "negative" practices (use of cough syrup, use of albuterol suspension, and preferential use of leukotriene modifiers instead of inhaled corticosteroids as the first line of preventive therapy). Response options were as follows: never, rarely, sometimes, and always, scored from 0 to 3. The two physician groups were compared on score means for the positive and negative practices using a t test with statistical significance set at p < 0.05.

Results: Overall, the rate of adherence to the positive practices was high, with no significant difference between the two groups. Negative practices, while present in both the groups, were reported significantly more often by the community-based group, particularly the use of cough suppressants and albuterol suspension.

Conclusions: Greater emphasis is needed to increase the awareness among PCPs of the NHLBI guideline recommendations, as suboptimal outpatient asthma management may contribute to the disproportionately higher hospitalization rates among inner-city asthmatic children. Clarification on the use of potentially harmful medications and those of doubtful value need to be incorporated in the guidelines. The extent to which these negative practices contribute to the elevated pediatric hospitalization rates warrants further investigation.

Key Words: asthma management • inner city • National Heart, Lung, and Blood Institute guidelines • pediatrics • primary care provider