Asthma, one of the most common disorders of childhood, exerts a substantial burden on young patients, families, and the health care system. Episodes of acute exacerbation result in frequent contact with physicians. The past decade has seen an emphasis on maximizing outpatient treatment highlighted by a new and expanded armamentarium of pharmacologic agents and methods of delivery. These newer forms of treatment allow physicians to adopt a wide range of clinical management strategies and create an enormous potential for variability in the office-based management of acute asthma. Recently the National Heart, Lung, and Blood Institute (NHLBI) and the coordinating committee of the National Asthma Education Program have published and disseminated detailed guidelines for asthma care. This major effort in shaping treatment strategies has occurred without knowledge of current asthma care practices, extent and correlates of variability in care, and the relationship of variability to clinical and functional outcomes. As ground work for a large scale, prospective cohort study relating variability in asthma care to patient outcomes, this preliminary project addresses the following questions: 1) What is the range of variability in the pediatric office-based management of acute asthma and how does this management differ from the NHLBI guidelines? 2) What is the interrater reliability of pediatricians in using a standardized clinical instrument in the assessment of acute asthma? 3) What is the feasibility of a set of family questionnaires to assess the short-term clinical and functional impact of an acute episode of asthma? This preliminary study will utilize a national network of community-based pediatricians from the Pediatric Research in Office Settings (PROS) Network of the American Academy of Pediatrics. Participating providers recruited from 30 PROS practices will collect data on the clinical and laboratory findings and treatment of children (ages 4 through 17 years) with acute asthma. Each provider will enroll 10 or more consecutive patients with acute asthma over a five month period, providing a sample size of 300 to 500 patients. Parents or caretakers will complete two questionnaires, one at enrollment to obtain baseline information on past medical history and disease activity and another 5 to 7 days after the initial clinical encounter to document short-term clinical and functional outcome. Providers will document subsequent care with a follow-up questionnaire 30 to 45 days after the index visit. Interrater reliability regarding clinical signs and symptoms will be assessed in a random subset of 20 paired providers performing simultaneous but independent assessments on 40 patients. Based on responses to questionnaires, scales will be created to document the severity of clinical presentation and to classify: 1) baseline disease activity and 2) success of outcome. Major analyses will be conducted to: 1) determine the extent of variation in clinical care, 2) compare the current standard of pediatric care with NHLBI guidelines, and 3) provide a preliminarily evaluation of the patient, practice, and structural factors associated with variability in management and success of outcome. Additional analyses will determine agreement between clinical raters and utility of assessment instruments in documenting clinical course and outcomes. The results of this preliminary project should allow determination of whether sufficient variability exists in acute asthma management in practice to warrant a larger study. In addition, information from this proposed project will fill a gap in the knowledge base about the current care of acute asthma in children and provide a basis for the ultimate evaluation of standards such as the NHLBI guidelines.
