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Published on: February 2, 2017
High physician adherence to phenotype-specific asthma guidelines, but large variability in phenotype assessment in
Francine M Ducharme1, Jonathan Morin, G Michael Davis
1Department of Paediatrics, University of Montreal, Research Centre, CHU Ste-Justine, Montreal, Quebec, Canada. francine.m.ducharme@umontreal.ca
Insights
Pediatric asthma phenotype classification varied, especially in young children, impacting controller medication adherence. Standardized assessment tools are crucial for consistent asthma management across all pediatric ages.
Area of Science:
- Pediatric Pulmonology
- Asthma Phenotyping
- Clinical Practice Guidelines
Background:
- International pediatric asthma guidelines rely on differentiating intermittent and persistent asthma phenotypes.
- Accurate phenotyping guides the prescription of phenotype-specific pharmacotherapy.
Purpose of the Study:
- To identify factors influencing specialist-confirmed asthma phenotypes in children.
- To evaluate physician adherence to asthma practice recommendations.
Main Methods:
- Retrospective electronic health record review of children (1-17 years) diagnosed with asthma.
- Analysis of phenotype determinants and adherence to phenotype-specific treatment.
Main Results:
- Asthma phenotypes varied within patients over time, particularly in preschoolers.
- Phenotype classification was physician-dependent and associated with age, severity, and triggers.
- 82% of persistent asthma cases received controller medication, compared to 33% of intermittent cases.
Conclusions:
- Pediatric asthma specialists demonstrated high adherence to phenotype-specific pharmacotherapy.
- Variability in phenotype assessment, especially in preschoolers, hindered controller medication prescription.
- Validated, standardized phenotype assessment tools are needed for all pediatric age groups.
Background:
The implementation of international pediatric asthma guidelines hinges on the distinction between intermittent and persistent phenotypes and the prescription of recommended phenotype-specific pharmacotherapy.
Objectives:
To ascertain key factors associated with specialist-confirmed phenotype and document physicians' adherence to practice recommendations in an academic pediatric asthma center.
Design/Methods:
Using electronic health records, we identified a cohort of children aged 1-17 years who presented to a tertiary-care asthma center between 2002 and 2007 and received a diagnosis of asthma from a pediatric specialist. Outcomes included: determinants of phenotypes and conformity with phenotype-specific treatment recommendations.
Results:
Of the 3490 eligible children (11,119 visits), most (47%) were preschoolers, 35% were 6-11 years and 18%, 13-17 years. Of children with confirmed asthma, 59% were classified on presentation as having intermittent, 41% as persistent, asthma. The within-patient phenotype varied over time with a consistency index of 0.76 (best=1); the latter was significantly lower in preschoolers than older children (p<0.0001). The persistent phenotype was highly physician-dependent; it was also positively associated with child's age, asthma severity, multiple triggers, calendar year, and duration of follow-up. Compared to 33% of children with intermittent asthma, 82% of those with persistent asthma were prescribed a maintenance controller, most as monotherapy; combination therapy was usually prescribed after a trial of monotherapy.
Conclusion:
Pediatric asthma specialists were highly adherent to phenotype-specific pharmacotherapy. However, even in an academic center, the notable degree of intra-patient and between-physician variation in phenotype, particularly in preschoolers, was an important impediment to prescribing a maintenance controller. The findings underline the importance of developing validated and standardized means of assessing phenotypes, applicable to the whole pediatric age spectrum.
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