title: Asthma treatment decisions by pediatric residents do not consistently conform to guidelines or improve with level of training.
abstract: OBJECTIVE
  To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training.
  
  
  METHODS
  We conducted a Web-based survey of residents from 10 training programs through the Continuity Research Network of the Academic Pediatric Association (CORNET). Surveys included 6 vignettes of patients receiving low-dose inhaled steroids with guideline- and non-guideline-based indicators of asthma status and 1 stable patient on high-intensity medication.
  
  
  RESULTS
  There were 369 resident respondents (65% response rate), 26% postgraduate year (PGY) 1, 38% PGY2, and 36% PGY3+. Seventy-five percent of each resident group reported seeing fewer than 1 asthma patient per continuity clinic session. A majority of residents made appropriate treatment recommendations in 2 of 4 vignettes of guideline-based indicators of asthma status: first, 97% overall stepping up treatment for mild persistent asthma; and second, 52% overall stepping down treatment for a patient with well-controlled asthma on high-intensity medications. Inconsistent with guideline recommendations, 82% of residents overall did not step down treatment for a patient with well-controlled asthma receiving low-intensity therapy; 75% of residents did not step up treatment for a patient with a recent hospitalization for asthma. Of the 3 vignettes evaluating non-guideline-based indicators of asthma status, a majority of residents (60%) stepped up treatment for parental reports of worse asthma, while a minority did so for a parental report of being bothered by their child's asthma (27%) or when wheezing was reported at physical examination (43%). There were no statistically significant differences for any of the comparisons by year in training.
  
  
  CONCLUSIONS
  Pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. There were no differences in the outpatient asthma management decisions between residents by years in training. Educational efforts should be focused on strategies to facilitate pediatric resident adherence to national asthma guideline recommendations for outpatient asthma management.
authors.affiliation: Division of Pediatric Pulmonology, The David Geffen School of Medicine at UCLA, Los Angeles, Calif. Electronic address: sokelo@mednet.ucla.edu.
authors.forename: Sande O
authors.initials: SO
authors.lastname: Okelo
authors.affiliation: Pediatric, Adolescent, and Maternal AIDS (PAMA) Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md.
authors.forename: George K
authors.initials: GK
authors.lastname: Siberry
authors.affiliation: Division of General Pediatrics & Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Barry S
authors.initials: BS
authors.lastname: Solomon
authors.affiliation: Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Bilderback
authors.affiliation: Department of Family, Population and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
authors.forename: Michiyo
authors.initials: M
authors.lastname: Yamazaki
authors.affiliation: Department of Pediatrics, New York Medical College, Valhalla, NY.
authors.forename: Theresa
authors.initials: T
authors.lastname: Hetzler
authors.affiliation: Department of Pediatrics, Oregon Health & Science University, Portland, Ore.
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Ferrell
authors.affiliation: Academic Pediatric Association, McLean, Va.
authors.forename: Nui
authors.initials: N
authors.lastname: Dhepyasuwan
authors.affiliation: Division of General Pediatrics & Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Janet R
authors.initials: JR
authors.lastname: Serwint
mesh_terms: D000328:Adult; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence / Q000706:statistics & numerical data*; D003657:Decision Making; D019468:Disease Management; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007396:Internship and Residency; D008297:Male; D010372:Pediatrics / Q000193:education*; D017410:Practice Guidelines as Topic
chemical_list: D018927:Anti-Asthmatic Agents
keywords: CORNET; asthma; decision making; pediatric resident education; survey; treatment; vignettes