Implementation and Effectiveness of Guideline-Recommended Clinical Activities for Children With Asthma. Population-Based Cohort

Medical record audits of primary care practices in the United States, Canada, and the United Kingdom suggest widespread suboptimal implementation of asthma guideline recommendations. Reasons are numerous, but there may be a perceived lack of benefit for patients. In the United Kingdom, more than 95% of scheduled asthma care is provided by primary care. The objective of this study was to determine the implementation of specific guideline-recommended clinical practices (GCPAs) and determine which children were less likely to receive these and their effectiveness at reducing exacerbations.A total of 126 483 five- to sixteen-year-old children with at least 3 asthma codes within 3 years. The study population was drawn from a longitudinal health care database of UK primary care medical records. This database covers approximately 20% of the United Kingdom. Records were individually linked to hospital admissions and emergency department (ED) data.Self-controlled case series methodology was used; each child acts as their own control and outcome events are compared prior to and following the exposure to the GCPA. These measures included asthma review (included an assessment of asthma control), inhaler technique check, and asthma management plan. Other variables included body mass index, socioeconomic status, smoking status, other atopic disease, asthma medications, and asthma exacerbations, defined as a short course of oral corticosteroids, ED visit, or hospitalization. The control period was considered the 12 months prior to guideline-recommended care, and the risk period was considered the 12 months after.In the first year following the asthma diagnosis, 56% received an annual asthma review, falling to 45% in subsequent years. Asthma management plans were provided to 42% in the first year, dropping to 30% thereafter. Inhaler technique checks were conducted in 59% in the first year and 40% in subsequent years. Children who received the GCPA were more likely to be male and older and have more severe asthma. Atopy and previous exacerbations did not distinguish those who received the GCPA. Children less likely to receive the GCPA included those with lower socioeconomic status, those with obesity, those not receiving inhaler prescriptions, and those of a younger age. Standalone annual asthma reviews were associated with a 6% reduction in exacerbations only during the first 6 months; standalone inhaler technique checks were not associated with a decrease in exacerbations, but standalone provision of an asthma management plan was associated with a 15% decrease in exacerbations that persisted. Provision of all 3 GCPAs during the same visit was associated with a 30% decrease in exacerbations that also persisted.Provision of GCPAs is underutilized in the United Kingdom, especially for all 3 given at the same visit. The most vulnerable at-risk children were the least likely to receive the GCPAs. Annual asthma reviews alone, and inhaler technique review alone, have no lasting effect on exacerbations, but asthma management plans alone do reduce exacerbations, and all 3 GCPAs at the same visit are most effective.Annual asthma visits were not noted to be effective, but the only stipulation for those are an assessment of asthma control, which could be minimal. This study adds to the evidence that guideline-recommended care is suboptimal in primary care, and most importantly, a comprehensive asthma visit with provision of all 3 GCPAs can have a significant impact on exacerbations.

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