Asthma--a problem of health care delivery. Is it time for a new paradigm?

Asthma is common, results in extensive morbidity and occasional mortality, and is associated with highly variable outcome. A major factor influencing outcome relates to physician decision making. Subspecialty directed asthma management has been demonstrated to favorably influence outcome of asthma to a greater extent than any other variable in care. National guidelines appear to have had little impact on primary care of asthma despite their widespread distribution. As a substitute for those extremely comprehensive and extensive guidelines, a small number of measures can be identified that are both realistically applicable in the primary care setting while having the greatest impact on outcome. These low intensity high yield measures, if applied, can substantially reduce emergency care requirements and hospitalizations. Patients not responding adequately to those measures should be identified early and referred to subspecialists for subsequent ongoing management.