Large care gaps in primary care management of asthma: a longitudinal practice audit

Courtney Price, Gina Agarwal, David Chan, Sanjeev Goel, Alan G Kaplan, Louis-Philippe Boulet, Muhammad M Mamdani, Sharon E Straus, Gerald Lebovic, Samir Gupta, Courtney Price, Gina Agarwal, David Chan, Sanjeev Goel, Alan G Kaplan, Louis-Philippe Boulet, Muhammad M Mamdani, Sharon E Straus, Gerald Lebovic, Samir Gupta

Abstract

Objectives: Care gaps in asthma may be highly prevalent but are poorly characterised. We sought to prospectively measure adherence to key evidence-based adult asthma practices in primary care, and predictors of these behaviours.

Design: One-year prospective cohort study employing an electronic chart audit.

Setting: Three family health teams (two academic, one community-based) in Ontario, Canada.

Participants: 884 patients (72.1% female; 46.0±17.5 years old) (4199 total visits; 4.8±4.8 visits/patient) assigned to 23 physicians (65% female; practising for 10.0±8.6 years).

Main outcome measures: The primary outcome was the proportion of visits during which practitioners assessed asthma control according to symptom-based criteria. Secondary outcomes included the proportion of: patients who had asthma control assessed at least once; visits during which a controller medication was initiated or escalated; and patients who received a written asthma action plan. Behavioural predictors were established a priori and tested in a multivariable model.

Results: Primary outcome: Providers assessed asthma control in 4.9% of visits and 15.4% of patients. Factors influencing assessment included clinic site (p=0.019) and presenting symptom, with providers assessing control more often during visits for asthma symptoms (35.0%) or any respiratory symptoms (18.8%) relative to other visits (1.6%) (p<0.01).

Secondary outcomes: Providers escalated controller therapy in 3.3% of visits and 15.4% of patients. Factors influencing escalation included clinic site, presenting symptom and prior objective asthma diagnosis. Escalation occurred more frequently during visits for asthma symptoms (21.0%) or any respiratory symptoms (11.9%) relative to other visits (1.5%) (p<0.01) and in patients without a prior objective asthma diagnosis (3.5%) relative to those with (1.3%) (p=0.025). No asthma action plans were delivered.

Conclusions: Major gaps in evidence-based asthma practice exist in primary care. Targeted knowledge translation interventions are required to address these gaps, and can be tailored by leveraging the identified behavioural predictors.

Trial registration number: NCT01070095; Pre-results.

Keywords: asthma; knowledge translation; primary care; quality in health care; respiratory medicine (see thoracic medicine).

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Proportion of visits* with each number of symptom-based asthma control questions asked. The stacked bar graph provides the number and proportion of visits during which each of one, two, three, four or five symptom-based control questions were asked by the clinician. *Among the 261/4122 visits in which any control question was asked.

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