Investigators from the University of California Los Angeles conducted a web-based survey using clinical vignettes to compare residents’ asthma treatment decisions to current asthma guidelines. Resident study participants were recruited from categorical pediatric and medicine-pediatric residency programs enrolled in CORNET (Continuity Research Network of the Academic Pediatric Association) from May to July 2008. This network encompasses 95 clinical practice sites representing 77 pediatric training programs across the United States; 10 programs agreed to participate. Participants were presented with 7 different clinical vignettes, each designed to test a particular component of asthma management, including (1) step up treatment, (2) step down treatment, and (3) influence of non-guideline factors on decision-making. Each scenario had a correct response that was consistent with treatment recommended in current guidelines.
Web-based surveys were completed by 369 of 568 eligible residents (65%). Virtually all residents at all levels indicated they would correctly step up therapy when presented with a patient with poor asthma control (frequent symptoms and albuterol use). However, a minority of residents indicated that they would step up therapy in 2 other vignettes where current guidelines recommend increasing treatment: wheezing on examination (41%–45% of residents would step up therapy) and recent hospitalization (25%–26% would step up therapy). No statistical differences were noted for correct response rates between training years for either of these scenarios. Results were somewhat similar for vignettes in which guidelines recommend stepping down therapy: high-intensity therapy without any other clinical risk factors (53% of PGY1s, 56% of PGY2s, and 48% of PGY3s would step down) and low-intensity therapy without any other clinical risk factors (18%, 13%, 22%, respectively); no significant differences were noted based on training level. For 2 scenarios involving criteria not included in current guidelines, a majority of residents at all training levels would step up therapy with parental report that the child’s asthma was worse than at the last visit (63%, 58%, 59%, respectively) and some would step up therapy with parental report of being “bothered” by their child’s symptoms (28%, 26%, 27%, respectively).
The authors conclude that pediatric residents’ management of asthma is consistent with national guidelines in some cases, but not in others, and that management decisions do not change with higher training level. They speculate that limited contact with asthma patients resulting from resident work-hour restrictions, and/or possibly inadequate supervision or teaching from pediatric clinic preceptors may have played a role in the lack of familiarity with asthma guidelines at all levels of pediatric training.
Dr Springer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
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