Asthma Guidelines : No Benefit for Patients ?

Practice guidelines for asthma by the National Asthma Education and Prevention Program (NAEPP) have been published in Expert Panel Reports beginning in 1991, with updates in 1997 and 2002. The most recent release is a 415 page Expert Panel Report 3. There is reason to question if these benefit patients, or if this extensive 20 years of well intentioned effort amounts to little more than mental masturbation. Despite extensive dissemination of these guidelines, data from the National Center for Health Statistics identify no decrease in asthma morbidity through 2005, the most recent U.S. data available. The publication stated ‘‘The most current data show that the challenges of childhood asthma remain and that asthma persists as a significant public health problem. ’’ Moreover, neither hospitalizations nor emergency room visits have decreased at most major U.S. Children’s hospitals through 2009. There is evidence that attempts to apply the Guidelines in clinical practice sufficiently to impact asthma care has not been highly successful. Difficulties include the problem of dissemination to primary care physicians who provide most asthma care. A second and related problem is the length and complexity of the Expert Panel Reports from the National Asthma Education Program which certainly complicates effective integration into primary care practice. In contrast to the apparent overall failure to improve outcome of asthma during the period since Guidelines have been developed and disseminated, specialty-based care programs have substantially improved outcome even prior to publication of Guidelines. In 1990, a report was published of 47 inner-city adult patients with troublesome asthma at Bellevue Hospital Center in New York who were randomly assigned to an intensive subspecialty directed outpatient program. Their outcome was compared with 57 patients continuing to receive routine care at the same institution. A threefold improvement in readmission was observed in the subsespecialty group during 8 months of follow-up compared with those who continued with routine care. An even earlier study demonstrated substantial difference in outcome for adult patients admitted to a U.K. Health Service Hospital. The admitting physician at the hospital alternated between a pulmonologist and a general internist. When the pulmonologist was the admitting physician, the asthmatic was admitted to a pulmonary unit, while on other days patients with asthma were admitted to a general medical unit. Ten-fold fewer readmissions occurred the following year among those admitted by the pulmonologist than among those admitted by the general internist. Specialty programs have subsequently been quite successful at demonstrating that asthma outcome in children can be substantially improved when care is provided in a specialty program where comprehensive care is provided by experienced personnel. This was demonstrated in a controlled trial of 80 children, ages 2–16, on Medicaid in Norfolk Virginia who were randomly assigned to remain in the general pediatric clinic or assigned to the allergy clinic at the Children’s Hospital of the King’s Daughters. That study demonstrated substantial improvement in outcome from specialty care, more than a twofold difference in ER visits