Does guideline knowledge affect treatment compliance among emergency doctors?

Assessing prescriber adherence with Global Initiative for Asthma (GINA) guideline-recommended reliever therapy

In 2019, a landmark change was made to the Global Initiative for Asthma (GINA) guidelines in which an as-needed low-dose inhaled corticosteroid (ICS)-formoterol inhaler was updated to be the preferred reliever therapy for all asthma patients. Use of short-acting beta-agonist monotherapy is no longer recommended. The purpose of this study was to assess provider adherence with the GINA guidelines in regards to reliever therapy. This was a retrospective cohort study of patients presenting with an acute asthma exacerbation from January to May of 2020 and 2021. The primary objective of this study was to quantify provider adherence with the GINA guidelines in terms of reliever therapy. Preferred reliever therapy was defined as use of an as-needed low-dose ICS-formoterol combination inhaler. Alternative reliever therapy was defined as use of a SABA inhaler with ICS-containing controller therapy. Secondary objectives included the number of patients discharged on any form of corticosteroid and the number of patients who may have been ideal candidates for transition to preferred reliever therapy. A total of 127 patients were included in the analyses. Upon hospital discharge, three patients (2.4%) received preferred reliever therapy and 97 (76.4%) received alternative reliever therapy. Rates of recommended reliever therapy prescription increased from 55 to 79% upon hospital discharge (p < 0.001). Prescription of GINA guideline-recommended reliever therapy was 79% within the patient population evaluated; however, rates significantly improved following hospitalization for asthma exacerbation. Additional studies that assess barriers to guideline adherence may be recommended.

Treatment for acute bronchiolitis before and after implementation of new national guidelines: a retrospective observational study from primary and secondary care in Oslo, Norway

BACKGROUND

Acute bronchiolitis treatment guidelines changed in Norway in 2013, no longer recommending the use of nebulised epinephrine. We aimed to assess whether these changes were successfully implemented in both primary and secondary care. Secondary aims were to compare the difference in management of acute bronchiolitis patients in primary and secondary care between 2009 and 2017.

METHODS

We retrospectively registered data on demographics, clinical features and management from electronic medical records of all infants (<12 months of age) diagnosed with acute bronchiolitis at a primary care centre (Oslo Accident and Emergency Outpatient Clinic) and a secondary care centre (Oslo University Hospital) in Norway in 2009, 2014 and 2017. All patient records were individually reviewed to ensure data accuracy.

RESULTS

We included 680 (36.3%) patients from primary care and 1195 (63.7%) from secondary care. There was a reduction in the use of nebulised epinephrine from 2009 to 2017 from 66.9% to 16.1% of cases (p<0.001) in primary care and from 59.1% to 4.9% (p<0.001) in secondary care. In parallel, there was an increase in the use of nebulised saline treatment, from 0.8% to 53.8% (p<0.001) in primary care and from 39.3% to 65.3% (p<0.001) in secondary care. The decrease in the use of nebulised racemic epinephrine occurred earlier in secondary care than in primary care; 13.4% vs 56.1%, respectively, in 2014.

CONCLUSIONS

Implementation of the new guidelines on the treatment of acute bronchiolitis was successfully implemented in both primary and secondary care.