Elsevier

Academic Pediatrics

Volume 14, Issue 3, May–June 2014, Pages 287-293
Academic Pediatrics

Research in Pediatric Education
Asthma Treatment Decisions by Pediatric Residents Do Not Consistently Conform to Guidelines or Improve With Level of Training

https://doi.org/10.1016/j.acap.2013.12.008Get rights and content

Abstract

Objective

To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training.

Methods

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.

Results

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.

Conclusions

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.

Section snippets

Procedures

A cross-sectional survey of pediatric residents was conducted between May 2008 and July 2008. Participation was limited to those who were residents at the time the study started (May 2008). An e-mail with a Web-based link to an online survey was sent to prospective residents whose continuity clinic practices were enrolled in the CORNET. Completion of the survey served as consent to participate in the study. Survey responses were anonymous. Institutional review board approval was obtained from

Respondent Characteristics

Of the 568 surveys sent to pediatric residents in the 10 participating programs, we received 367 complete responses (overall 65% response rate). Three hundred twenty-seven (89%) were categorical pediatric residents, and 40 (11%) respondents were internal medicine–pediatric residents. Year in training was unrelated to demographic and practice characteristics except for self-rated asthma experience (Table 2), where PGY1 residents were less likely than PGY2 or PGY3+ residents to report moderate or

Discussion

In this vignette-based survey of a national sample of pediatric residents, we observed the following: 1) a majority of residents recommended treatment in accordance with asthma guidelines for 2 of the 4 guideline-based vignettes (97% stepping up treatment for mild persistent symptoms; 52% stepping down treatment for well-controlled symptoms); 2) a majority of residents recommended treatment for only 1 of 3 focus group based (nonguideline) indicators of asthma morbidity (60% stepping up for

Conclusions

The findings from this study demonstrate that pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. Additionally, there were no meaningful differences in the outpatient asthma management between residents of different years in training. Future efforts should be focused on developing strategies to facilitate pediatric residence adherence to management strategies that conform to national guideline recommendations and to adaptation of

Acknowledgments

We appreciate the efforts of our site coinvestigators: Baystate Medical Center: Matthew Sadof, MD; Children's Memorial Hospital, Northwestern University: Sandra M. Sanguino, MD, MPH; DeVos Children's Hospital: William Stratbucker, MD; College/Westchester: Theresa Hetzler, MD; North Carolina Children's Hospital: Michael Steiner, MD; University of Texas at Houston: Michelle S. Barratt, MD, MPH, and Lisa de Ybarrondo, MD; University of Texas Health Sciences at San Antonio: Pamela Wood, MD;

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    Similar studies have been done in various medical subspecialties to identify shortfalls that require further effort in educating residents. Okelo et al. conducted a web-based survey in 369 pediatric residents focusing on asthma management [19]. No difference was found between residents by years in training.

The authors declare that they have no conflict of interest.

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