Suboptimal management of asthma: Does it only happen elsewhere?

Pediatric Pulmonology 33:81±82 2002) DOI 10.1002/ppul.10055 Editorial Suboptimal Management of Asthma: Does It Only Happen Elsewhere? Richard L. Henry, MB, BS, MD, FRACP, Dip Clin Epi* Bridging the gap between research and clinical practice is important to ensure optimal care for our patients. 1 Research groups are keen to publish positive outcomes related to quality assurance. Two recent papers about con- verting clinical practice in acute asthma from nebulizers to spacer devices 2,3 were accompanied by editorial com- ments 4,5 applauding the success and encouraging others to adopt the practice. Lenney 5 made the observation about one factor limiting the adoption of contemporary research into clinical practice: ``There remains an egotistical feeling that the study was not carried out as well as `we' would have done it and it doesn't really apply to `our' patients.'' The opposite end of the quality assurance spectrum is when clinical practice in individual units falls below de- sired standards. Two recent papers 6,7 reported on asthma management in children admitted to intensive care units. Undoubtedly there will be many readers who will dismiss the paper from Eshel et al. 7 due to the stark contrast between the optimal care that occurs in their own hospitals with inadequate treatment practices occurring elsewhere. Indeed, this is such a common perception that one often hears doctors talk about treatment at ``St. Elsewhere's.'' This is a perjorative term that encapsulates the attitude that Lenney 5 criticized in his commentary. The setting for the paper in this edition of the Journal is Israel. Both study hospitals were well-resourced, and pediatric pulmonologists served as consultants in the care of most of the children admitted to the intensive care units with acute severe asthma. As might be expected with this group of patients, nearly 60% had been hospita- lized in the past. Nine of the 84 had more than 5 previous admissions, and 13 of the 84 had recurrent admissions to intensive care in the previous 5 years. By any criteria, these children had identi®ed themselves as having signi®cant clinical problems. Less than one third of the cohort were receiving regular inhaled corticosteroids, and it was common for children to receive regular beta-2 agonists as the sole maintenance therapy. Management of the acute exacerbation prior to admission to hospital was characterized by failure to commence oral corticosteroids in a timely fashion. There was a lack of documentation of existence or use of asthma management plans, data on levels of adherence, asthma knowledge, or even symptom frequency and background control of asthma between episodes. The authors highlighted the discontinuity between the acute care of these children in hospital and their preventive care. Even in children admitted to an intensive care unit, follow-up did not always occur. Furthermore, lack of medical resources was not the explanation. A similarly bleak audit was published by Dakin et al. 6 Twenty-three percent of her study population had a previous admission to intensive care. Only 29% were on inhaled corticosteroids, and follow-up was erratic. Persis- tent asthma was undertreated, and asthma management did not conform to available guidelines. Others have also documented inadequate asthma management. 8 Evidence of inadequate prescribing of preventive medication and poor adherence to therapy was found in a group admitted to a large children's hospital. Forty-four percent had previously been given a written asthma management plan, but only 9% of them had used it before the current hospital admission. Eshel et al. 7 express shock at the sobering evidence from their study. They should be congratulated for their honesty in presenting their ®ndings. They also provide sound advice to review our own practices, on the basis Department of Paediatrics, School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia. *Correspondence to: Professor R. L. Henry, School of Women's and Children's Health, Sydney Children's Hospital, High Street, Randwick, New South Wales 2031, Australia. Received 18 October 2001; Accepted 18 October 2001. ß 2002 Wiley-Liss, Inc.

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Suboptimal management of asthma: Does it only happen elsewhere?