Good intentions of new asthma guidelines hampered by reality
Bringing caregivers and patients on board
The National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, MD, released a groundbreaking set of asthma guidelines in 1991 and followed that effort with an impressive update last year. There have been lectures, slide presentations, direct mailings, and a variety of patient education leaflets to get the message out. But is anyone listening?
Not many people are, according to a study published recently in Archives of Internal Medicine that found adherence to the guidelines was poor.1 Guidelines for the Diagnosis and Management of Asthma, compiled by a panel of the nation's top asthma experts, for the first time emphasized prevention through early diagnosis, the use of preventive medicines such as inhaled steroids, and regular peak flow monitoring.
But just because the advice is good doesn't mean physicians in the trenches are changing their methods of treatment. What's an asthma program to do? Experts recommend targeting physicians with smaller chunks of information, aggressively involving patients in their own treatment, and letting physicians and patients see comparative data on their progress.
The study in Archives compared the status of disease management of 5,580 asthmatic members of a California health maintenance organization (HMO) with the standards set forth in the 1991 NHLBI guidelines and found adherence sorely lacking:
· 72% of those with severe asthma reported having a steroid inhaler, but only 54% used it daily, as recommended by the guidelines.
· 26% reported having a peak flow meter, but only 16% used it daily. The guidelines recommend using the device twice a day.
· 42% reported they were given self-management tools such as what to do for a severe episode of asthma, how to adjust medications, and how to avoid asthma triggers. The guidelines recommend that physicians or nurses provide this information to each patient.
"It's not that doctors don't want to do the right thing," says Antonio P. Legorreta, MD, MPH, lead author of the study and vice president for Foundation Health Systems in Woodland Hills, CA. Foundation runs Health Net, the HMO in the study. "It's that the practicing physician isn't necessarily familiar with the guidelines. There is a place for guidelines; they give you a nice framework in which to manage patients. But instead of continuing to develop new guidelines, what we need to develop is a guideline to disseminate the guidelines."
Devising a physician education plan
It's tough to think of a good way to get the guidelines in the hands of every physician who needs them, Legorreta says. And even if you could, physicians aren't exactly crazy about having a government agency or an HMO tell them how to treat patients. "If they want to learn about asthma, they will look at peer journals," he says. "You can put the same data in an HMO binder, and they won't look at it. We need to come up with a way to communicate to physicians that their patients will be better off if they follow these guidelines. But we have to do it in a way that hits home."
NHLBI's National Asthma Education and Prevention Program is looking for ways to hit home with physicians, says coordinator Robinson Fulwood, MSPH. For the 1991 guidelines, the program used a mass dissemination plan with direct mail to asthma-related groups, a lecture series at its annual meetings, and development of a speakers' bureau. To add credibility, it had the guidelines published in two peer-reviewed journals. Those activities are being continued, but now NHLBI is narrowing its focus from simply getting the word out to getting the guidelines implemented.
In March, NHLBI sponsored a national conference called "Managing Asthma in Managed Care" with the intent of finding ways to get the guidelines implemented in large health care delivery systems, particularly those that serve high-risk and underserved populations disproportionately affected by asthma. As a result, several HMOs have agreed to form a collaborative to look at ways to change their asthma efforts.
Guidelines target primary care docs
NHLBI also broke down different portions of the guidelines into culturally and age-appropriate educational tools for physicians to use, Fulwood says. Two laminated desk cards, one for adults and one for children, give physicians a summarized, step-by-step approach to long-term drug therapy. There's also a one-page summary of the major points of the guidelines and a 10-page patient education pamphlet, an initial set of which is free to managed care companies. And there's a whole catalog of other educational materials that explain different points of the guidelines.
Harold Nelson, MD, a member of the NHLBI guideline panel and senior staff physician at National Jewish Medical and Research Center in Denver, says the panel did its best to keep the update as short as possible so physicians wouldn't have so much to wade through. The 1991 asthma guidelines had 136 pages; the update had 86.
"Specialists already do what's suggested by the guidelines because they're current on the medical literature," Nelson says. "So the guidelines are directed at the primary care physician who doesn't have time to read all those studies. But if he doesn't read the studies, he might not read the guidelines either."
Nelson says it's disappointing to think the guidelines may not have their intended effect, but he says they still need to exist. "We took all the literature and focused the information to make it accessible," he says. "We put it in a user-friendly format with a lot of tables and charts. The physician isn't going to be able to do that himself."
But with more than 1,000 clinical guidelines out there for different diseases, Legorreta says, it's impossible to expect a general practitioner to read them all, much less implement their recommendations. He says the key to changing physician behavior - besides making the information more manageable - is to show physicians how following the guidelines could affect their patients.
A set of baseline information should be collected on patients to assess their needs and desires, and differences such as age and ethnicity should be identified. Aggressive education programs for the physician and patient should be developed with evidence-based proof that such behaviors as using peak flow meters improve health status. "You need more than a balloon-and-party-hat approach to wellness," he says. "You can't just give out T-shirts and think you've solved the problem."
Health plans could also issue report cards that let physicians compare their treatment to their peers and pay could be based on outcomes, Legorreta says. Give those report cards to patients as well, and you're likely to see changes. "Let them vote with their feet for which physicians they will go to," he says. "Market forces will influence physician behavior."
In fact, Legorreta says, putting some of the responsibility on patients' shoulders and making sure they have the knowledge and the devices they need (such as peak flow meters) would also improve guideline adherence. He recommends disseminating some form of the guidelines to patients themselves, not just to physicians. "Educating the consumer can be better than educating the physician," he says. "In the past, we have patronized patients with chronic conditions by assuming they couldn't understand clinical guidelines. But this is fundamentally wrong. Eighty percent of the population is invested in the stock market, and a high proportion of those read the stock tables every day. And we are afraid they can't handle simple guidelines?"
It's not just the physician's fault that asthmatics sometimes don't get optimal treatment. "Patients have to take responsibility for their own disease," Legorreta says. "They need to learn to ask questions. But we have to provide them with the tools. We can ask them to take better care of themselves, but how can they do that if we don't give them a peak flow meter?"
In Legorreta's study, patients reported high levels of satisfaction with the quality of their care, even though their treatment was not up to the standards in many cases. "That suggests that patients are accepting a level of functional status that they don't have to accept," Fulwood says.
Fulwood says every patient should have an action plan that tells them what to do in case of an asthma attack. Someone in the physician's office should go over how to use such devices as inhalers at every patient visit. "Make the patient demonstrate how to use a peak flow meter and how to use their action plan," Fulwood says. "Reinforce it each time and put something about it in their hands when they leave."
[For more information about asthma guidelines, contact the following:
· Antonio Legorreta, MD, Quality Initiatives Division, Health Net, 21600 Oxnard St., 11th Floor, Woodland Hills, CA 91367. Telephone: (818) 719-6775.
· Robinson Fulwood, MSPH, Office of Prevention, Education and Control, NHLBI, NIH, Building 31, Room 4A-18, Bethesda, MD 20892. Telephone: (301) 496-1051.
· Harold Nelson, MD, National Jewish Medical and Research Center, 12400 Jackson St., Denver, CO 80206. Telephone: (303) 398-1562.
For information on the managed care collaborative, contact:
· Kevin Weiss, MD, Center for Health Services Research, Rush Primary Care Institute, 1653 W. Congress Parkway, Chicago, IL 60612.]
Reference
1. Legorreta A, et al. Compliance with national asthma management guidelines and specialty care. Arch Intern Med 1998; 158:457-464.
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