Asthma Guidelines: Invited Commentaries.
It has now been nearly a decade since the National Heart, Lung, and Blood Institute of the National Institutes of Health published recommendations for the diagnosis and treatment of asthma (1). While these guidelines underwent a modest updating in the late 1990s (2), their message has been consistent and clear. Asthma should be viewed as an inflammation of the airways rather than just a problem of airway hyperresponsiveness. Standardized routine assessment of the airways and clear disease classification of severity should be the foundation for planning. Early use of anti-inflammatory medications should be the treatment of choice for all but the mildest intermittent expression of the disease. Finally, a solid patient-provider partnership is needed to ensure appropriate asthma education, written action plans, and eventual self-management skills. The national guidelines have been widely disseminated, and a number of recent studies suggest that the vast majority of surveyed health care providers are aware of them (3-5). However, regardless of the widespread knowledge of these guidelines, mounting evidence indicates that physicians have not fully adopted them into practice (6-8). The article by Gipson et al provides additional evidence of the gap between the availability and use of asthma clinical care guidelines (9). The authors conducted chart audits to determine whether key processes related to asthma care were documented during routine patient visits. The authors report that many of the key elements of care were not routinely documented. They also note that although these performance measures appeared more frequently in the charts of asthma specialty clinics, even within that environment, there were clear opportunities to improve care. These findings, while interesting, are not all that unexpected. Several countries with well-established asthma care guidelines have documented (via chart audit) deficiencies in care for persons with asthma (10-12).