This study reports on a survey that took place one year after the National Asthma Education Program Expert Panel (NAEP) published guidelines to assist physician and patient decisions regarding appropriate asthma management. The goal of the study was to assess whether the outpatient management of asthma in adult patients was concordant with these guidelines. Data were drawn from the adult medical services of the Johns Hopkins Hospital and the Johns Hopkins Bayview Medical Center between February 1992 and January 1993. Patients who received an admitting diagnosis of asthma or reactive airway disease were interviewed within 48 hours of admission. Of the 101 patients interviewed, 73% were black and 27% were white. Eighty-three percent of the patients had been previously hospitalized for asthma, and the average number of emergency visits in the past years was 6.5l; thus, these patients were considered to have moderate to severe conditions.

The NAEP guidelines recommend that inhaled corticosteroids should be used as the first-line pharmacologic agents (together with beta-agonists) for moderate or severe asthma. In this survey, only 45 patients were prescribed inhaled corticosteroids. However 69 patients received theophylline (a third-line medication by the guidelines), 27 received oral steroids, and 1 received nasal steroids. Eighty-five patients received beta-agonist Metered Dose Inhaler (MDI), 30 nebulizer, and 8 oral. Further, since inhaled medication delivered with a Metered Dose Inhaler are first-line therapy according to the guidelines, patients were asked to demonstrate their MDI technique. Eighty-four patients stated that a health care professional had instructed them in the use of an MDI, but only 11% could demonstrate all components correctly. Patient education was also lacking.

Racial group was significantly associated with number of emergency room visits in the past year (blacks had 8.1 visits versus 2.3 for whites), number of hospital admissions within the past year (blacks had 3.2 admissions versus 0.7 for whites), and use of beta-agonist MDI within 24 hours of admission (blacks received 56.7 "puffs" versus 24.4 for whites). With regard to related variables, blacks were intubated more often, more frequently increased beta-agonist use without recommendation for their physician, and were more likely to have medial assistance as a form of medical reimbursement. Other asthma treatment and prescription variables did not differ by race.

Stepwise regression models were then performed to identify the best independent predictors of asthma severity (the sum of emergency room visits and admission over a one-year period) as well as of beta-agonist usage. The strongest predictors were the number of asthma medications and black race. Although not statistically significant, younger age of onset was associated with worse severity and seeing asthma specialists was associated with less severity. Among patients whose exacerbation lasted 24 hours, the strongest predictors of high usage of beta-agonists were older age, being a smoker, and black race. Asthma severity was not a statistically significant predictor of beta-agonist usage. SES (measured by type of insurance) did not predict severity or beta-agonist usage.

The authors conclude that chronic asthma care in this urban populations of patients with moderate to severe asthma is characterized by sub-optimal medical management that is reflected by under-utilization of anti-inflammatory agents, inadequate inhaler technique, lack of action plans (education) and of aggressive treatment by physicians during exacerbations and extensive usage of inhaled beta-agonists. Limitations include use of self-reported data and limited data on risk factors for asthma severity (the multiple R value was 0.477 for the asthma severity multiple regression analysis).