title: Asthma treatment in a population-based cohort: putting step-up and step-down treatment changes in context.
abstract: OBJECTIVE
  To assess the frequency and types of visits related to modifications in the intensity of asthma medications.
  
  
  METHODS
  We retrospectively reviewed the medical records of adults (aged 18-40 years) and children (aged 6-17 years) living in Olmsted County, Minnesota, to evaluate changes in asthma medications by dose and drug class and site and type of visit (routine vs unscheduled) at the time of changes. All records from all visits were reviewed for each patient to identify asthma-related visits at all sites of care from January 1, 2002, through December 31, 2003.
  
  
  RESULTS
  The study consisted of 397 adults and children. In 255 patients, 597 asthma medication changes occurred. Step-up changes usually occurred because of an exacerbation or loss of control of asthma and adhered to the medication hierarchy in the national asthma guidelines. Twenty step-up changes involved skipping inhaled corticosteroid (ICS) monotherapy and moving directly to combined ICSs plus a long-acting beta-agonist (LABA). Lack of documentation of asthma symptom frequency or interference with activities made it impossible to determine whether these 'skips' were appropriate. Only 78 physician-directed step-down changes were documented, usually to a lower dose of combined ICSs and LABAs or a move from combined ICSs and LABAs to anti-inflammatory monotherapy. Patients initiated additional step-down changes between encounters. Step-down changes occurred at routine or follow-up asthma visits, but the limited number of such visits provided few opportunities for step-down care.
  
  
  CONCLUSIONS
  The continuing episodic-style treatment of asthma aimed at exacerbation management facilitates step-up changes in asthma therapy. The dearth of asthma evaluation visits limited opportunities to step down use of asthma medications and to provide long-term asthma management.
authors.affiliation: Department of Research, Olmsted Medical Center, 210 Ninth St SE, Rochester, MN 55904, USA. Yawnx002@umn.edu
authors.forename: Barbara P
authors.initials: BP
authors.lastname: Yawn
authors.forename: Peter C
authors.initials: PC
authors.lastname: Wollan
authors.forename: Susan L
authors.initials: SL
authors.lastname: Bertram
authors.forename: David
authors.initials: D
authors.lastname: Lowe
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Butterfield
authors.forename: Denise
authors.initials: D
authors.lastname: Bonde
authors.forename: James T C
authors.initials: JT
authors.lastname: Li
mesh_terms: D000280:Administration, Inhalation; D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage; D000328:Adult; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D009819:Office Visits / Q000706:statistics & numerical data; D012189:Retrospective Studies
chemical_list: D000305:Adrenal Cortex Hormones; D000318:Adrenergic beta-Agonists