Assessing Primary Care Physician’s Beliefs and Attitudes of Asthma Exacerbation Treatment and Follow-Up

INTRODUCTION

Asthma exacerbations are often associated with lack of asthma control. They can be severe enough to lead to emergency department (ED) visits or hospital admissions, and even death [1]. Patients who have exacerbations requiring an ED visit, hospitalization, or intensive care unit admission are at greater risk of exacerbations in the future. In addition, severe asthma exacerbations can occur in patients across the spectrum of disease severity including patients considered to have “mild” asthma [2-4]. Asthma guidelines indicate that disease awareness education, follow-up care and assessment of appropriate use of long-term controller medications should be priority items in the discharge planning of patients from the ED or hospital [1]. In a study by Singh and colleagues, 31% of patients overall used the ED first when experiencing asthma problems, and 22% reported the ED as their usual source of asthma prescriptions. Even in patients with a PCP, 10% used the ED as their primary provider of asthma medications [5]. Importantly, studies have shown that approximately 70% of patients do not receive controller medications, such as inhaled corticosteroids, on discharge from the ED [6, 7]. The reason for this is not well understood. It may be that ED staff focuses solely on treating the current acute event or physicians assume patients will receive these medications upon follow-up with their PCP.

Therefore, we sought to assess adult primary care physician and pediatrician perceptions of asthma exacerbation management, including beliefs concerning the discharge of patients from the ED following asthma exacerbations.

METHODS

RESULTS

A total of 189 physicians were sent the final survey, with 124 (65%) returning a completed survey. Among the 124 respondents, there were 56 adult primary care physicians and 68 pediatricians. This sample of physicians was geographically dispersed across the US (25% Midwest, 22% Northeast, 25% South, and 28% West).

The majority of physicians agreed that an exacerbation is defined as worsening asthma requiring a course of oral corticosteroids (83%). However, ≥70% of physicians agreed that an exacerbation could also include events which did not require OCS, but rather, resulted in increased use of rescue albuterol for two or more consecutive days or required an inhaled or nebulized albuterol intervention in the physician’s office or prompted the need to change maintenance medications (Fig. 1). When asked to rank events most likely to trigger an exacerbation, both adult and pediatric PCPs ranked poor compliance with asthma medication, common cold or flu or allergen exposures the highest. Pediatric PCPs were more likely to rank common cold or flu as the primary trigger while adult PCPs were more likely to rank poor compliance with asthma medication as the primary trigger. When asked about which season Adult PCPs see the most asthma exacerbations, 45% reported winter, 30% reported fall, 23% reported spring, 0% reported summer, and 5% reported they do not see any seasonal differences. When Pediatricians were asked the same question, 48% reported fall, 39% reported winter, 13% reported spring, 0% reported summer, and 0% reported they do not see any seasonal differences.

Overall, 71% of All PCPs believed that the majority of their patients’ asthma exacerbations were treated in the doctor’s office. Further, 19% believed treatment usually occurred in the patient’s home, 6%, the ED, another 4% in urgent care, and 3% said they did not know. Approximately half of the PCPs (55% of adult PCPs and 43% of pediatricians) said they were notified of their patient’s ED visit or hospitalization within a few days of the event, whereas 27% and 49%, respectively, were notified at the time of hospital visit. Only 4% of adult and 10% of pediatric PCPs were notified of an urgent care visit at the time of the event. Approximately 20% of adult and 10% of pediatric PCPs said they are never notified of an ED visit for asthma and became of aware of these events later (Table 1). On the other hand, results show that a large percentage (40%) of adult PCPs said they receive no notification of their patient’s visit to an urgent care center for an exacerbation; this percentage is less (29%) for pediatric providers. When adult PCPs and pediatricians were notified that their patient had been treated for an asthma exacerbation in the ED, the majority (91%) required a follow-up visit in the office “all of the time or most of the time”. In contrast, only 73% stated that they followed-up through an in-office visit for patients who treated an exacerbation at home. The majority of physicians surveyed (79%) indicated that if a controller medication was warranted, the ED or urgent care staff should initiate treatment at time of discharge.

DISCUSSION

Exacerbations consist of a sustained, often progressive, deterioration in asthma symptoms and airflow obstruction that occurs over hours to days and can last for days to weeks, where additional medications and/or emergency care is often needed. These attacks generally allow time for intervention; however, a few patients have a rapid onset or a severe asthma exacerbation and require immediate medical attention [8]. In this survey most PCPs reported that the majority of their patient’s asthma exacerbations were treated in the doctor’s office. These findings suggest that the intensity of the exacerbations could have been perceived as not too severe and therefore, required a less aggressive intervention. This could be also a function of the interpretation or definition of an exacerbation. In 2008 the National Health Interview Survey (NHIS) included the following question to their asthma prevalence survey, “During the past 12 month months, have you had an episode of asthma or an asthma attack?” [9]. The use of the term “asthma attack” appears to be in recognition of a broader definition of exacerbations that may be less severe but still clinically important. Considering the significant impact these “asthma attacks” have on the patient and the need for a clinical response, perhaps the primary care physician’s definition is also appropriate with the modifier of mild or moderate exacerbation. The burden of uncontrolled asthma may be under reported considering that these milder events may not be captured in many epidemiological surveys that track asthma morbidity. Therefore, a broader, common definition of an asthma exacerbation between all health care providers may help the precision for reporting serious episodes of worsening asthma and in turn, increase quality of care for millions of patients with asthma. In addition, patients seen in the sites surveyed may have been more likely not to use the ED for less severe events or for events that occurred during normal office hours.

An interesting difference between responses of adult PCPs and pediatricians was the season when providers observe the greatest number of asthma exacerbations. For adult PCPs, the majority reported winter as being the season when they observe the most exacerbations in their patient population. On the other hand, the majority of pediatricians reported fall as the season when they observe the greatest number. This difference may in fact relate to the start of school in younger asthmatics.

PCPs questioned in this survey stated they were usually notified within a few days of an ED visit in the majority of cases, with pediatricians reporting being notified 90% of the time. This number may be an over-estimate since it represents only the events the PCP was made aware of at a later date. Over 90% of PCPs surveyed said they scheduled a follow-up with their patients “all or most of the time” when notified of an ED visit for an asthma exacerbation. Also evident from the data collected was that PCPs are less aware of urgent care visits for asthma than for ED visits or hospitalizations. These results highlight the importance of having consistent communication to allow follow-up with patients in a timely manner and possibly preventing further asthma morbidity.

The majority of physicians surveyed (79%) indicated that, if a controller medication was warranted, the ED or urgent care staff should initiate treatment at time of discharge. National guidelines for the treatment of asthma suggest that sufficient medication be prescribed so that patients may continue treatment until follow-up [1]. Despite the current evidence supporting the role of anti-inflammatory controller agents in the management of chronic asthma, data suggest that few ED physicians prescribe these agents at the time of discharge, perhaps thinking that the patient’s primary care physician will address this at follow-up [10]. However, many patients may not see their primary care physician soon enough after an exacerbation, and even when they do, many do not receive inhaled corticosteroids. Also, for many patients with asthma without a PCP, the ED may be their primary source of care [5]. Patients who present to the ED with acute asthma are often under-treated prior to the event, or are non-adherent to their asthma management plan [5, 6]. This was confirmed as most PCPs in our study identified poor medication compliance as a significant trigger for exacerbations. These patients may benefit from a reassessment of their asthma management plan, including starting controller therapy, since it has been found that inhaled corticosteroids initiated at ED discharge were most often continued at follow-up by the primary care physician [11]. Knowing that the majority of PCPs felt it was acceptable for a controller medication to be initiated in the ED may help remove one of the obstacles and perception associated with prescribing asthma controller medications at discharge. To facilitate continuity of care, ED physicians should also consistently provide summaries of care received and medications prescribed to the patient’s PCP.

LIMITATIONS

There are some limitations to the present study design and survey methodology. The overall sample was geographically diverse with a response rate of over 60%, however physicians that responded to the survey may not have been fully representative of overall PCP population of the US Due to the small sample size within each region, we were not able to stratify results by region or practice dynamics (e.g. size of practice) so it is unknown if any differences exist.

Another potential limitation is that the survey was qualitative in nature and written to elicit opinions of the physician based on physician experience and recall. Therefore, further studies would need to be conducted to quantify these findings.

CONCLUSIONS

This study showed that healthcare providers may not share a common definition of an asthma exacerbation. In addition, most physicians believe that the majority of exacerbations are treated in their office or at home. Further, most agreed that if a controller medication was warranted, the ED or urgent care staff should initiate treatment.

REFERENCES