Guidelines and realities of asthma management - The Philadelphia Story

Background: Guidelines from the National Heart, Lung, and Blood Institute, Bethesda, Md, have encouraged more frequent use of inhaled steroids in asthma management. Objectives: To determine (1) whether prescription rates for inhaled steroids have increased compared with prescriptions for bronchodilators and (2) significant associations of demographic factors with bronchodilator-inhaled steroid prescription ratios and with rates of inhaled steroid prescriptions. Design: Cross-sectional analysis of monthly bronchodilator and inhaled steroid prescription rates, numbers and types of asthma care providers, and demographic factors. Setting: Philadelphia, Pa. Measurements: Using univariate and multivariate analyses, bronchodilator and inhaled steroid prescription rates were determined for 45 ZIP codes and studied for associations with race and ethnicity, poverty, educational attainment, marital status, gender, total numbers of asthma drug prescriptions, and numbers and types of asthma care providers. Results: Monthly bronchodilator-inhaled steroid prescription ratios increased from July 1991 to June 1993 (P<.001). Prescription rates for inhaled steroids and inhaled bronchodilators declined, but rates for oral bronchodilators (beta-agonists and theophylline) increased By stepwise multiple regression, higher bronchodilator-inhaled steroid prescription ratios and lower inhaled steroid prescription rates were each significantly associated with ZIP codes in which greater proportions of residents lacked a high school diploma (P<.001), associations that approached statistical significance were found for higher bronchodilator-inhaled steroid ratios and fewer asthma care providers (P=.05) and for lower inhaled steroid prescription rates and lower proportions of asthma specialists (P=.04). Conclusions: In Philadelphia, a gap exists between optimal asthma aug prescribing and actual prescribing patterns that has widened from July 1991 to June 1993. Under-use of inhaled steroids is most closely associated with lower educational attainment, suggesting that interventions that include addressing the special asthma care needs of a low-literacy population will be required to achieve the goals of the National Asthma Education Program.