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Background: Asthma guidelines recommend severity assessment to assign treatment, often quantified as current control. It is unknown how strongly control assessment affects clinician treatment decisions, nor if control is sufficient., Methods: To determine patient factors used by physicians to assign treatment, we surveyed pulmonary specialists (PSs) and family physicians (FPs) using vignettes. We tested whether recent acute care (hospitalization 6 months ago), bother (patient bothered by asthma), control (symptom or reliever medication frequency), and direction (change since last visit) influence treatment decisions. Factors used for stepping up and stepping down were assessed., Results: A total of 461 physicians participated (236 PSs and 225 FPs). As expected, physicians indicated a greater likelihood of stepping up treatment for persistent (4-5 times per week) than for intermittent (1 time per 2 weeks) symptoms (PSs 97% vs 24%, P < .001; FPs 97% vs 33%, P < .001). All else being equal, physicians were more likely to step up treatment of a patient with intermittent symptoms if the patient reported recent acute care (PSs 49% vs 24%; FPs 72% vs 33%), was bothered (PSs 81% vs 24%; FPs 80% vs 33%), or was worse since the last visit (PSs 68% vs 24%; FPs 66% vs 33%) (all P < .001). These factors were also predictive of stepping down from high-intensity therapy and remained significant in multivariate analyses (all P < .05)., Conclusions: Asthma control greatly influences physician decisions about asthma treatments. However, recent acute care, bother, and direction of illness also influence decisions, particularly those that involve increasing the amount of medication prescribed. Further work is needed to determine if use of these additional indicators leads to better asthma outcomes.

Background: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent cause of hospitalization in the United States. Previous studies of selected populations of patients with COPD have estimated in-hospital mortality to range from 4% to 30%. Our objective was to obtain a generalizable estimate of in-hospital mortality from acute exacerbation of COPD in the United States and to identify predictors of in-hospital mortality using administrative data., Methods: We performed a cross-sectional study utilizing the 1996 Nationwide Inpatient Sample, a data set of all hospitalizations from a 20% sample of nonfederal US hospitals. The study population included 71 130 patients aged 40 years or older with an acute exacerbation of COPD at hospital discharge. The primary outcome assessed was in-hospital mortality., Results: In-hospital mortality for patients with an acute exacerbation of COPD was 2.5%. Multivariable analyses identified older age, male sex, higher income, nonroutine admission sources, and more comorbid conditions as independent risk factors for in-hospital mortality., Conclusions: Mortality during hospitalization in this nationwide sample of patients with acute exacerbations of COPD was lower than that of previous studies of select populations. This estimate should provide optimism to both clinicians and patients regarding prognoses from COPD exacerbations requiring hospitalization. Our results indicate that the use of administrative data can help to identify subsets of patients with acute exacerbations of COPD that are at higher risk of in-hospital mortality.

Background: Asthma undertreatment has been linked to poor outcomes. National guidelines recommend that physicians classify asthma severity based on pretreatment symptoms and titrate care as the disease changes in the individual patient. This study evaluated the extent to which the physician estimate of underlying severity affects a patient's asthma care., Methods: Data used were collected from a cohort of adults with asthma enrolled in managed care. Eligible patients were adults enrolled in managed care with medical encounters coded for asthma. Physicians were eligible if they were main asthma providers. The patient survey covered demographics, symptoms, asthma treatment, and self-management knowledge. Physicians were asked to assess the underlying severity of their patients' asthma., Results: There were 4005 patients with asthma with physician estimates of underlying severity. Of the patients, 70.1% were female (mean age, 44.8 years) and 83.5% were white. Most patients' current asthma symptoms were moderate (39.4%) and severe (50.1%). Most physician estimates of underlying severity were mild (44.6%) and moderate (44.5%). Among those patients reporting moderate symptoms, daily inhaled corticosteroid use was reported in 35.2% when physician estimates were mild, 53.0% when moderate, and 68.1% when severe (P =.001). Rates of peak flowmeter ownership, allergy testing, and self-management knowledge tracked similarly with physician estimates of underlying severity., Conclusions: Physician estimates of underlying asthma severity appear to determine asthma care. For patients with inadequate symptom control, lower physician estimates of underlying severity were associated with care that is less consistent with national guidelines. To improve the quality of asthma care, physicians need to update treatment based on their patients' current symptoms and adapt care accordingly.

Background: Although older adults (> or =65 years) with asthma have higher rates of hospitalization and death from asthma than younger adults, the reasons for this are not known., Objectives: To determine whether patterns of care were less favorable for older than younger adults with asthma and to assess whether patient characteristics such as symptom severity and comorbid illnesses explain the higher rate of hospitalization., Methods: Prospective cohort study of 6590 adults with asthma in 15 managed care organizations in the United States. Participants completed a survey of demographics, symptoms, health status, comorbid illnesses, treatment, access to care, self-care knowledge, physician specialty, and health care use., Results: Among 6590 adults with asthma, 554 (8%) were 65 years or older and 1942 (29%) were aged 18 to 34 years. Older patients were more likely than younger patients to be men, white, non-Hispanic, and less educated. At baseline, older patients reported a greater frequency of asthma-related symptoms, such as daily cough (36% vs 22%, P<.001) and wheezing (27% vs 22%, P<.002). They were also more likely to report comorbid conditions, such as sinusitis (50% vs 38%), heartburn (35% vs 23%), chronic bronchitis (43% vs 16%), emphysema (19% vs 1%), congestive heart failure (8% vs 1%), and history of smoking (54% vs 34%) (all P<.001). Care appeared to be better for the older patients compared with the younger, including more frequent use of inhaled corticosteroids, greater self-management knowledge, and fewer reported barriers to care. In the follow-up year, older patients were approximately twice as likely to be hospitalized (14%) than were younger patients (7%) (P<.001). In multivariate analysis, however, older age was not predictive of future hospitalization (odds ratio, 1.05; 95% confidence interval, 0.68-1.61), after adjustment for sex, ethnicity, education, baseline asthma symptoms, health status, comorbid illnesses, and tobacco use. Factors independently associated with hospitalization included being female, nonwhite, less educated, and less physically healthy, and more frequent asthma symptoms., Conclusions: Although the older adults with asthma had greater respiratory symptoms and more comorbidity than their younger counterparts, chronologic age was not an independent risk for hospitalization. Appropriate care for older adults with asthma should address asthma symptoms and other chronic conditions.