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Pediatric Asthma Education in Primary Care

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Asthma is one of the most common chronic diseases in childhood, with more than 10 million patients diagnosed before age 18.1 The prevalence of childhood asthma doubled between 1980 and the mid-1990s, and it has remained at historically high levels over the past decade.2

Like asthma incidence, asthma severity has not improved. In 2008, the most recent year for which comprehensive statistics are available, children between ages 5 and 17 who had at least one asthma attack missed an average of 10.5 days of school.3 In the nonemergent ambulatory setting, more than 7 million visits by patients younger than 18 were attributed to asthma that year, with the highest healthcare use among children ages 0 to 4.3 These primary care and emergency visits have significant implications for the families of children with asthma, for schools, and for the healthcare system at large. The cost of treating asthma in children is estimated at more than $3 billion per year.4,5

Asthma treatment guidelines are readily available, but research shows that healthcare providers don't do a good job of following them, resulting in a high prevalence of poor asthma control.6,7 The National Asthma Education and Prevention Program (NAEPP) has published specific recommendations for asthma education in children. Research demonstrates that asthma education for children is associated with a reduction in the mean number of hospitalizations and ED visits and an increase in the number of nonscheduled clinic visits.8 This reflects improved patient understanding of good asthma control and early recognition of asthma symptoms.8

Given the high prevalence of asthma in children and the associated frequency of visits to primary care clinics for asthma-related complaints, NPs and PAs in primary care are positioned to serve as the asthma patient's primary source of education. Thus, is it important to be familiar with key components of effective asthma management and to routinely provide thorough asthma education. This article provides recommendations for incorporating asthma education standards into clinical practice in the pediatric primary care setting.

National Guidelines

The NAEPP, a program initiated by the National Heart, Lung and Blood Institute (NHLBI), commissioned a panel of experts to develop national guidelines for the diagnosis and management of asthma. The first guidelines were published in 1991, with subsequent updates in 1997, 2002 and 2007. The NHLBI 2007 Expert Panel Report 3 (EPR-3) represents the most comprehensive effort to define care and management protocols for asthma patients, including a heightened emphasis on patient and caregiver education. The EPR-3 places an increased emphasis on education by calling for the following:

  • teaching and reinforcement of self-monitoring to assess level of asthma control and symptoms of worsening asthma
  • written asthma action plans developed by the provider and patient
  • teaching to ensure each patient understands which medications to use and how to use them
  • recognition and avoidance of environmental triggers.

Most importantly, the EPR-3 encourages providers to offer individualized self-management programs and to integrate education into each maintenance visit by a patient with asthma.9

Common Themes

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Improved asthma management is a goal throughout the world. A comparison of guidelines from the NAEPP, the Global Initiative for Asthma and health organizations in Canada, Australia and the United Kingdom shows similar emphasis on effective asthma education for patients, caregivers and clinicians. All of these guidelines state that good asthma self-management improves long-term asthma outcomes and behavioral modification. Specific training in various self-management skills is essential to produce positive outcomes in chronic conditions such as asthma.10 Common viewpoints in these documents and current literature are as follows:

• Clinicians should routinely review each patient's asthma action plan and assess the patient's understanding and adherence to the treatment plan and medication regimen.9,10

• Collaborative partnerships between patients and clinicians are the best strategy for achieving optimal asthma outcomes.9-11

• Education should begin at diagnosis, and patient understanding of this education should be reviewed and reinforced at each visit.9,10

• Asthma education for children should be developmentally focused.9,10,12,13

• Clinicians should explain asthma in easy-to-understand language.9,10

• Clinicians should routinely review with patients the signs and symptoms of good asthma control versus poor asthma control.9,10,14-16

• Clinicians should routinely review with patients the role of all asthma medications.9,10,16-18

• Regular education about peak flow monitoring and medication delivery devices, including technique reviews, are essential.4,9,10,16,17

• Written asthma action plans are ideally developed jointly between the patient and clinician.9,10,16

• Asthma education is important for both the clinician and the patient.4,9,10,13,19,20

The table accompanying this article outlines recommended educational elements to be addressed at diagnosis and at follow-up visits.9,12

Common Pitfalls

To provide effective asthma education, it is important to understand some of the common pitfalls associated with inadequate or absent asthma education. Research shows that providing asthma education to families increases parents' asthma knowledge and decreases asthma morbidity in their children.6,21 How the information is conveyed is as important as the information itself.

Importantly, some patients find that written information about asthma medication is unclear or confusing unless the provider gives detailed instruction and reviews these instructions on a regular basis.18 Also of note, it is common for children to use incorrect inhaler technique.4

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Primary care providers are likely to be the primary and most influential information source for patients, so it is important to provide patient education in an individualized, personally relevant manner. Do not rely on printed patient education materials alone, and frequently observe medication delivery techniques.6,18,19

Education models in which information is provided in an interactive, face-to-face encounter are more effective in reducing asthma severity than models in which personal interaction is not the mainstay.6,21 A motivated healthcare professional teaching in a dedicated individualized or small-group setting is the best tool for providing effective asthma education.21

Who Should Educate?

NAEPP guidelines recommend that a child's principal clinician initiate asthma education and counseling and that all members of the healthcare team provide education.9 As healthcare practices have incorporated more NPs, PAs and support personnel, the responsibility for providing asthma education has broadened to a larger number of people with more diverse backgrounds and training. While some practices employ a collaborative approach, others rely only on the principal clinician, who may be a physician, NP or PA.

A review of pediatrician attitudes and practices with regard to collaborative asthma education in 10 regions of the country found that most (64%) of the practices surveyed employed a collaborative approach, relying on allied health professionals to have extensive involvement in asthma education.18 The survey defined allied health professionals as NPs, PAs, RNs, medical assistants and respiratory therapists.

Research shows that the most effective pediatric primary care practices embrace a collaborative approach to care.6 The collaborative care model includes asthma care visits with a trained asthma clinician, provider adherence to a standardized approach to the assessment of asthma control, a commitment to include patient participation in care planning, and attention to providing self-management support for families.6

The EPR-3 guidelines recommend that asthma self-management education be integrated into all aspects of asthma care and involve all members of the healthcare team.9 Given the expanding demands on clinician time in primary care and the recognition of the importance of adherence to national asthma guidelines, efforts to improve asthma management in children should rely on a collaborative organizational model for asthma management.

Charting Implications

Asthma guidelines recommend documenting asthma severity at each clinic visit.20 Research shows this isn't always done. A review of 276 medical records detailing 1,236 primary care visits to nine university-owned pediatric primary care clinics for possible asthma symptoms found that only 34% included any documentation of asthma severity in the past 2 years, and only 11% contained asthma action plans.20

Research has documented an association between documentation of asthma severity and receipt of an asthma action plan, prescription of a spacer device, prescription of a peak flow meter, and receipt of asthma education.20

Providers who document asthma severity consistent with the NHLBI severity criteria (intermittent, mild, moderate, severe persistent) are more likely to also provide other asthma control elements recommended by national standards for asthma management (self-care monitoring, face-to-face education, written asthma action plans, etc.).

Thus, documentation of asthma severity can be a marker for monitoring the comprehensiveness of asthma care, with classification of asthma severity compelling the nurse practitioner or physician assistant to move past acute treatment toward long-term management of the condition.20

Proper documentation of clinic visits also affects reimbursement. ICD-9 codes and procedural terminology codes for asthma care must be adequately supported by chart documentation to ensure optimal and timely reimbursement.20 Therefore, clinicians should provide routine assessment of asthma severity and control to help guide treatment decisions based on the NHLBI guidelines.

At each visit, nurse practitioners and physician assistants should review and teach self-management techniques that can help reduce asthma severity level and optimize symptom control. They should consistently document these practices in the chart to ensure appropriate reimbursement for the level of care provided.

Integral to Care

Asthma is a common chronic condition in children that is best managed in the primary care setting. Asthma education is integral to moving the treatment of this disease away from a focus on acute-care needs and toward improved long-term patient outcomes.

Nurse practitioners and physician assistants are well suited to providing optimum care as both clinicians and educators. This requires familiarity with asthma education standards as well as the diligent incorporation of key components of asthma education and management in daily clinical practice. 

References

1. Centers for Disease Control and Prevention. Summary health statistics for U.S. children: National Health Interview Survey, 2009. http://www.cdc.gov/nchs/data/series/sr_10/sr10_247.pdf. Accessed June 16, 2011.

2. Akinbami LJ. The state of childhood asthma, United States, 1980-2005. Adv Data. 2006;(381):1-24.

3. Akinbami LJ, et al. Asthma prevalence, health care use, and mortality: United States, 2005-2009. Natl Health Stat Report. 2011;(32):1-14.

4. Mellon M, Parasuraman B. Pediatric asthma: improving management to reduce cost of care. J Manag Care Pharm. 2004;10(2):130-141.

5. Weiss KB, et al. Trends in the cost of illness for asthma in the United States, 1985-1994. J Allergy Clin Immunol. 2000;106(3):493-499.

6. Miller K. Is there a better model for asthma care? Am Fam Physician. 2005;72(4):690.

7. Miller K. Physician prompting improves asthma preventive care. Am Fam Physician. 2007;75(12):1847-1848.

8. Coffman JM, et al. Effects of asthma education on children's use of acute care services: a meta-analysis. Pediatrics. 2008;121(3):575-586.

9. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007. NIH publication 08-4051.

10. Myers TR. Guidelines for asthma management: a review and comparison of 5 current guidelines. Respir Care. 2008;53(6):751-769.

11. Stoloff SW. Improving adherence to asthma therapy: what physicians can do. Am Fam Physician. 2000;61(8):2328, 2330, 2337.

12. Ladebauche P. Managing asthma: a growth and development approach. Pediatr Nurs. 1997;23(1):37-44.

13. Mitka M. New evidence-based guidelines focus on treatment of children with asthma. JAMA. 2008;299(10):1122-1123.

14. Dozier A, et al. What is asthma control? Discrepancies between parents' perceptions and official definitions. J Sch Health. 2006;76(6):215-218.

15. Wechsler ME. Managing asthma in primary care: putting new guideline recommendations into context. Mayo Clin Proc. 2009;84(8):707-717.

16. Kemp JP, Kemp JA. Management of asthma in children. Am Family Physician. 2001;63(7):1341-1354.

17. Plaut TF. Basic elements of asthma education. Am J Asthma Allergy Pediatricians. 1991;4(4):220-222. http://www.pedipress.com/dm_basic_elements_edu.html. Accessed June 16, 2011.

18. Hartig MT. Patients with chronic asthma found medicine information to be unclear or confusing, did not receive complete information on medicine use and side effects, and found leaflets to be unhelpful. Evid Based Nurs. 2005;8(1):28.

19. Cabana MD, et al. Pediatrician attitudes and practices regarding collaborative asthma education. Clin Pediatr (Phila). 2004;43(3):269-274.

20. Cabana MD, et al. Documentation of asthma severity in pediatric outpatient clinics. Clin Pediatr (Phila). 2003;42(2):121-125.

21. Liu C, Feekery C. Can asthma education improve clinical outcomes? An evaluation of a pediatric asthma education program. J Asthma. 2001;38(3):269-278.

Patty Lynch is a family nurse practitioner at South Sound Pediatric Associates in Olympia, Wash. She has completed a disclosure statement and reports no relationships related to this article.




     

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