Care of asthma patients in relation to guidelines.

Clinical asthma care may have to change to be brought in line with Expert Panel Report 3 (EPR3) guidelines, which recommend increased intensity of therapy (steps) to treat uncontrolled asthma. This study determined if asthma therapy steps can be identified using claims data and if patients have appropriate step-up in therapy if their disease is not controlled. A cohort study was performed using an administrative claims database and involving patients 12-64 years old with uncontrolled asthma events (either impairment or risk). Patients were assigned to a preindex step (6 months before the index date) and postindex steps (1 year after the index date). The primary study outcome was a change in therapy steps. We used logistic regression to identify variables predictive of an increase in step. Our algorithm for assigning steps appeared internally valid; patients identified as being at higher steps saw more specialists and had higher levels of asthma risk. Among 14,781 patients for which a step-up option existed, 12.4-41.3% had a step-up in therapy after an uncontrolled asthma event. For all steps, high-risk patients had higher odds of having a step-up in therapy than low-risk patients. The odds ratio for appropriate therapy increased with increasing baseline step: from 1.50 for step 2 versus step 1, to 11.41 for step 5 versus step 1. Steps can be assigned using claims data. Bringing care in line with EPR3 guidelines will require significant changes from current practice but will improve quality by reducing use of oral corticosteroids and increasing use of inhaled steroids.