Uncovering Persistent Asthma In Health Supervision Visits
Howard, B.J., Sturner, R., Okelo, S. Vullo, G., Berger, M.
Asthma is one of the most common chronic conditions in childhood affecting 9-11% of children and increasing. Continuity of care for asthma is recommended by NHLBI guidelines at a frequency of 1-6 months depending on severity/control and as part of the medical home. Primary Care Providers (PCPs), however, report caring for asthma primarily during health supervision visits at which an asthma monitoring tool is less likely to be done. In a NY state program, asthma-specific visits occurred in only 48% of cases.
Objective: To determine the severity/control levels of children with asthma presenting for health supervision vs asthma-specific visits.
In the current study, an electronic system was used in 26 community pediatric practices across the US for collecting pre-visit data including Visit Priorities (e.g. Breathing or cough) and the presence of an Asthma diagnosis before health supervision visits. If an asthma diagnosis was endorsed a validated asthma monitoring questionnaire (Pediatric Asthma Control and Communication Instrument of PACCI) was automatically administered that collects interval symptoms and other information resulting in an asthma severity/control level. The PACCI was also completed prior to asthma-specific visits in these practices.
Of the 33,366 health supervision visits, 2138 (6.4%) included an asthma diagnosis per the Priorities questionnaire. When “Breathing or cough” was one of the top 2 priorities asthma severity/control ratings were: 125 Intermittent/Well-Controlled; 79 Mild Persistent/Partly Controlled; 62 Moderate Persistent/Uncontrolled; 30 Severe Persistent/Very Poorly Controlled. When “Breathing or cough” was not endorsed as a top priority there were 1323 Intermittent/Well-Controlled; 340 Mild Persistent/Partly Controlled; 187 Moderate Persistent/Uncontrolled and 65 Severe Persistent/Very Poorly Controlled ratings. In contrast, in visits specifically for asthma, 1900 were Intermittent/Well-Controlled; 720 Mild Persistent/Partly Controlled; 465 Moderate Persistent /Uncontrolled and 186 Severe Persistent/Very Poorly Controlled.
Of parents attending asthma visits, 42% reported persistent asthma vs 78% attending health supervision visits. This better control may reflect more attention by these parents and/or PCPs to careful management when an asthma-specific visit was made. It may also reflect a failure to attend or schedule asthma-specific visits by some groups of parents or PCPs.
Parents of 34% of children with persistent asthma attending health supervision visits did not list breathing or cough as a priority. Health supervision visits represent a critical opportunity for improving asthma management. PCPs have been shown to do poorly in determining severity by routine questions. Use of a monitoring questionnaire can facilitate valid assessment of asthma symptoms and determination of the need for change in management which may be overlooked based only on parent concern during health supervision visits.