Evidence-based practice for children with asthma in primary care : quality of management and effects of learning

Sammanfattning: Background: Asthma is the most common chronic disease among children in Sweden. Many school-aged (7-17 years), but also preschool (0-6 years) children with asthma are managed in primary care. Evidence-based guidelines have been developed to support the use of current best clinical evidence in practice and to ensure high quality care. However, there is a gap between the actual care provided for children with asthma and the recommendations stated in the guidelines. Aim: To investigate the evidence-based practice for children with asthma in primary care. We wanted to evaluate the potential influence of quality of management and effects of learning to apply the evidence-based guidelines in routine care. Methods: In study I register data regarding dispensed prescriptions was collected. Dispensed prescriptions were followed over 24 consecutive months for all children (0-16 years) visiting 14 primary health care centres (PHCs) and initiated on anti-asthmatic drugs during one year (n=1033). In study II physicians and nurses participated in interactive education in these PHCs. 14 PHCs served as controls. Register data was collected regarding dispensed prescriptions and recorded diagnosis during 24 months before and after the intervention. Data was included from all children (0-17 years) (n= 114 175) listed at the 28 PHCs 2006-2012. Focus group interviews (FGIs) were used in study III to evaluate how general practitioners (GPs) approach, learn from and use evidence-based guidelines in their decision-making. Qualitative content analysis was used. 22 GPs participated. In study IV quality of care was assessed as a composite of quality indicators (CQI). Adherence to quality indicators was retrieved by scrutinising electronic health care records at 14 PHCs. By using the multivariate regression analysis orthogonal projection to latent structures (OPLS) the relationship between CQI and contextual features was evaluated. Results: In study I 54% of the school-aged children had only one prescription dispensed and 50% of them were initiated on short-acting beta2-agonist (SABA) as monotherapy. In study II 66% of the school-aged children with a recorded diagnosis of asthma were dispensed SABA as well as an anti-inflammatory anti-asthmatic drug before the intervention. There was no significant statistical difference between the intervention and control group at baseline or at follow-up. Approximately one-fourth of all children who were dispensed anti-asthmatic drugs did not have a recorded diagnosis of asthma. In study III three themes were conceptualised in the evaluation of the guidelines: Learning to use guidelines by contextualised dialogues; Learning that establishes confidence to provide high quality care; Learning by the use of relevant evidence in the decision-making process. In study IV more scheduled time for asthma care, lower age-limit for performing spirometry, lower duty-grade for GPs and higher activity at the educational seminars were the contextual features with highest influence on CQI. Conclusion: Most GPs show good adherence to evidence-based guidelines regarding pharmacological treatment in children with a recorded diagnosis of asthma. Correct diagnosis of asthma is crucial to enable use of evidence-based guidelines. To achieve this, spirometry needs to be performed more often. Contextualised dialogue, based on own experience, feedback on own results and easy access to short guidelines that were perceived as trustworthy, were important aspects for the use of the guidelines. To allocate time, interprofessional collaboration and to create an organisational structure with opportunities for engagement in asthma care, are contextual features that have the potential to facilitate evidence-based practice for children with asthma.