Okelo Sande O, Siberry George K, Solomon Barry S, Bilderback Andrew L, Yamazaki Michiyo, Hetzler Theresa, Ferrell Cynthia L, Dhepyasuwan Nui, Serwint Janet R
Division of Pediatric Pulmonology, The David Geffen School of Medicine at UCLA, Los Angeles, Calif.
Pediatric, Adolescent, and Maternal AIDS (PAMA) Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md.
Acad Pediatr. 2014 May-Jun;14(3):287-93. doi: 10.1016/j.acap.2013.12.008. Epub 2014 Mar 12.
To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training.
We conducted a Web-based survey of residents from 10 training programs through the Continuity Research Network of the Academic Pediatric Association (CORNET). Surveys included 6 vignettes of patients receiving low-dose inhaled steroids with guideline- and non-guideline-based indicators of asthma status and 1 stable patient on high-intensity medication.
There were 369 resident respondents (65% response rate), 26% postgraduate year (PGY) 1, 38% PGY2, and 36% PGY3+. Seventy-five percent of each resident group reported seeing fewer than 1 asthma patient per continuity clinic session. A majority of residents made appropriate treatment recommendations in 2 of 4 vignettes of guideline-based indicators of asthma status: first, 97% overall stepping up treatment for mild persistent asthma; and second, 52% overall stepping down treatment for a patient with well-controlled asthma on high-intensity medications. Inconsistent with guideline recommendations, 82% of residents overall did not step down treatment for a patient with well-controlled asthma receiving low-intensity therapy; 75% of residents did not step up treatment for a patient with a recent hospitalization for asthma. Of the 3 vignettes evaluating non-guideline-based indicators of asthma status, a majority of residents (60%) stepped up treatment for parental reports of worse asthma, while a minority did so for a parental report of being bothered by their child's asthma (27%) or when wheezing was reported at physical examination (43%). There were no statistically significant differences for any of the comparisons by year in training.
Pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. There were no differences in the outpatient asthma management decisions between residents by years in training. Educational efforts should be focused on strategies to facilitate pediatric resident adherence to national asthma guideline recommendations for outpatient asthma management.
比较儿科住院医师的哮喘治疗决策与当前哮喘指南，并了解治疗决策是否因培训的研究生年级而异。
我们通过学术儿科学会的连续性研究网络（CORNET）对来自10个培训项目的住院医师进行了一项基于网络的调查。调查包括6个接受低剂量吸入性糖皮质激素治疗的患者案例，这些案例具有基于指南和非基于指南的哮喘状态指标，以及1例接受高强度药物治疗的稳定患者。
共有369名住院医师回复（回复率65%），其中26%为研究生一年级（PGY1），38%为PGY2，36%为PGY3及以上年级。每个住院医师组中75%的人报告说，在每次连续性门诊中见到的哮喘患者少于1例。在4个基于指南的哮喘状态指标案例中的2个案例中，大多数住院医师做出了适当的治疗建议：第一，总体上97%的人对轻度持续性哮喘加强了治疗；第二，总体上52%的人对接受高强度药物治疗且哮喘得到良好控制的患者减少了治疗。与指南建议不一致的是，总体上82%的住院医师没有对接受低强度治疗且哮喘得到良好控制的患者减少治疗；75%的住院医师没有对近期因哮喘住院的患者加强治疗。在评估非基于指南的哮喘状态指标的3个案例中，大多数住院医师（60%）对家长报告哮喘恶化的情况加强了治疗，但对于家长报告因孩子哮喘而烦恼（27%）或体检时报告有喘息（43%）的情况，只有少数住院医师这样做。在培训年份的任何比较中均无统计学显著差异。
儿科住院医师对哮喘的管理在某些情况下与国家指南一致，但在其他情况下并非如此。住院医师在门诊哮喘管理决策方面，按培训年份划分没有差异。教育工作应侧重于促进儿科住院医师遵守国家哮喘指南中关于门诊哮喘管理建议的策略。
