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Gregory B. Diette, MD, MHS; Cecilia M. Patino, MD; Barry Merriman, MA; Laura Paulin, MHS; Kristin Riekert, PhD; Sande Okelo, MD; Kathy Thompson, RN; Jerry A. Krishnan, MD, PhD; Ruth Quartey, PhD; Deanna Perez-Williams, PhD; Cynthia Rand, PhD

Arch Intern Med. 2007;167(13):1360-1366.

Background  Asthma guidelines recommend severity assessment to assign treatment, often quantified as current control. It is unknown how strongly control assessment affects clinician treatment decisions, nor if control is sufficient.

Methods  To determine patient factors used by physicians to assign treatment, we surveyed pulmonary specialists (PSs) and family physicians (FPs) using vignettes. We tested whether recent acute care (hospitalization 6 months ago), bother (patient bothered by asthma), control (symptom or reliever medication frequency), and direction (change since last visit) influence treatment decisions. Factors used for stepping up and stepping down were assessed.

Results  A total of 461 physicians participated (236 PSs and 225 FPs). As expected, physicians indicated a greater likelihood of stepping up treatment for persistent (4-5 times per week) than for intermittent (1 time per 2 weeks) symptoms (PSs 97% vs 24%, P < .001; FPs 97% vs 33%, P < .001). All else being equal, physicians were more likely to step up treatment of a patient with intermittent symptoms if the patient reported recent acute care (PSs 49% vs 24%; FPs 72% vs 33%), was bothered (PSs 81% vs 24%; FPs 80% vs 33%), or was worse since the last visit (PSs 68% vs 24%; FPs 66% vs 33%) (all P < .001). These factors were also predictive of stepping down from high-intensity therapy and remained significant in multivariate analyses (all P < .05).

Conclusions  Asthma control greatly influences physician decisions about asthma treatments. However, recent acute care, bother, and direction of illness also influence decisions, particularly those that involve increasing the amount of medication prescribed. Further work is needed to determine if use of these additional indicators leads to better asthma outcomes.

Author Affiliations: Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine (Drs Diette, Patino, Riekert, Krishnan, and Rand and Ms Thompson), Department of Epidemiology, Bloomberg School of Public Health (Drs Diette and Krishnan and Mr Merriman), and Department of Pediatrics (Dr Okelo), The Johns Hopkins University, Baltimore, Maryland; School of Medicine, University of Massachusetts, Worcester (Ms Paulin); and Department of Epidemiology, Howard University, Washington, DC (Drs Quartey and Perez-Williams).

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