Impact of the national asthma guidelines on internal medicine primary care and specialty practice.

OBJECTIVE To evaluate documentation of compliance with the National Asthma Education and Prevention Program publication Guidelines for the Diagnosis and Management of Asthma. DESIGN A retrospective review of 114 charts coded as asthma. Fourteen chart evaluation questions were developed based on the 4 management components in the guidelines: assessment and monitoring of asthma, control of asthma factors, pharmacotherapy, and patient education. SETTING A hospital-based asthma clinic, a private pulmonary group, and a general internal medicine group in Dallas, Texas. RESULTS Nearly all physicians documented inquiries about daytime asthma symptoms, but only 64% of pulmonary group and 58% of internal medicine physicians documented inquiries about nighttime symptoms. In addition, in 14% of pulmonary group charts and 74% of internal medicine charts, no spirometry or peak flow data were documented. Most asthma clinic and pulmonary group charts (98% and 78%, respectively) included a history of triggers, but the pulmonary group and internal medicine group were more likely to document administration of the influenza vaccine than the asthma clinic (25% and 26% vs 13%). Of 38 patients with > or = 1 recorded forced expiratory volume in 1 second <60%, all but 1 were on inhaled steroids. However, many charts lacked adequate documentation to match drug selection to asthma severity. The asthma clinic group documented the 4 educational interventions 65% to 83% of the time, compared with the pulmonary group, at 17% to 50%, and the internal medicine group, at 5% to 18%. CONCLUSIONS Results showed significant variation with the recommendations. Areas in particular need of improvement were objective diagnosis and assessment, control of asthma-associated factors, and patient education. Furthermore, the study demonstrated significant variation between specialists and primary care physicians, with the more specialized clinics demonstrating better guideline compliance.