Finkelstein J A, Lozano P, Shulruff R, Inui T S, Soumerai S B, Ng M, Weiss K B
Harvard Medical School/Harvard Pilgrim Health Care, Boston, Massachusetts, USA.
Pediatrics. 2000 Oct;106(4 Suppl):886-96.
To determine self-reported adherence to national asthma guidelines for children by primary care physicians in managed care; and, to analyze sources of variation in these practices by physician specialty and managed care practice type.
A survey of 671 primary care physicians (pediatricians and family physicians) practicing in 3 geographically diverse managed care organizations (MCO). Domains of interest included asthma diagnosis, pharmacotherapy, patient education and follow-up, and indications for specialty referral. Item formats included self-reports of usual practice and responses to case vignettes.
A total of 429 (64%) physicians returned surveys, 22 of whom did not meet criteria for inclusion in the analysis. Most respondents had both heard of (91%) and read (72%) the National Asthma Education and Prevention Program (NAEPP) guidelines. For diagnosis, 75% reported routine use of office peak flow measurement, but only 21% used spirometry routinely. Family physicians were more likely than pediatricians to use spirometry in diagnosis (odds ratio [OR] = 5.9), and less likely to recommend daily peak flow measurement (OR =.3). The median reported frequency of providing written care plans was only 50%. Though inhaled corticosteroids were deemed very safe or safe by 93%, almost half had specific concerns regarding at least 1 side effect, most commonly growth delay. Primary care physicians' criteria for referral to an asthma specialist differed from those of the NAEPP panel in choosing to manage more severe patients without asthma specialist input. Family physicians were more likely than pediatricians to refer a child after a single hospitalization, 2 to 3 emergency department visits, after 2 exacerbations, or if the child was <3 years old and required daily medications. Responses to vignettes showed generally appropriate initial use of antiinflammatory agents, but reluctance to increase the dose in response to continued symptoms, and less frequent follow-up than recommended by the NAEPP.
Most physicians for children report having read and adopted NAEPP guideline recommendations for asthma treatment, including generally appropriate use of medications. Opportunities for improvement exist in specific areas such as the use of written care plans, optimizing antiinflammatory dosing, and providing routine follow-up. Although physicians show evidence of awareness of national guidelines and knowledge consistent with much of their content, additional work is required to promote the use of self-management tools in practice.
确定管理式医疗中初级保健医生自我报告的对国家儿童哮喘指南的遵循情况；并分析这些实践中因医生专业和管理式医疗实践类型而异的差异来源。
对在3个地理位置不同的管理式医疗组织（MCO）中执业的671名初级保健医生（儿科医生和家庭医生）进行调查。感兴趣的领域包括哮喘诊断、药物治疗、患者教育与随访以及专科转诊指征。项目形式包括通常实践的自我报告以及对病例 vignettes 的回答。
共有429名（64%）医生回复了调查问卷，其中22名不符合纳入分析的标准。大多数受访者（91%）听说过且（72%）阅读过国家哮喘教育与预防计划（NAEPP）指南。对于诊断，75%的医生报告常规使用诊室峰值流量测量，但只有21%的医生常规使用肺功能测定。家庭医生在诊断中比儿科医生更有可能使用肺功能测定（优势比[OR]=5.9），而推荐每日峰值流量测量的可能性较小（OR=0.3）。报告的提供书面护理计划的频率中位数仅为50%。尽管93%的医生认为吸入性糖皮质激素非常安全或安全，但几乎一半的医生对至少一种副作用有特定担忧，最常见的是生长发育迟缓。初级保健医生转诊至哮喘专科医生的标准与NAEPP小组不同，他们选择在没有哮喘专科医生参与的情况下管理病情更严重的患者。家庭医生比儿科医生更有可能在儿童单次住院、2至3次急诊就诊、2次病情加重后或如果儿童<3岁且需要每日用药后转诊。对 vignettes 的回答显示，抗炎药的初始使用总体上适当，但不愿因症状持续而增加剂量，且随访频率低于NAEPP的推荐。
大多数儿童医生报告已阅读并采用NAEPP哮喘治疗指南建议，包括药物的总体适当使用。在书面护理计划的使用、优化抗炎药剂量以及提供常规随访等特定领域仍有改进空间。尽管医生表现出对国家指南的认识以及与指南大部分内容一致的知识，但仍需要更多工作来促进自我管理工具在实践中的使用。
