Annals of Thoracic Medicine
ORIGINAL ARTICLE
Year
: 2006  |  Volume : 1  |  Issue : 1  |  Page : 20--25

Impact of an extensive asthma education campaign for physicians on their drug prescription practices


Abdullah Al-Shimemeri1, Hend Al-Ghadeer1, Hema Giridhar1, Hamdan Al-Jahdali1, Mohamed Al-Moamary1, Javid Khan1, Abdullah Al-Mobeireek2, Abdullah Al Wazzan3,  
1 Pulmonology Section, Department of Medicine, King Abdul-Aziz Medical City and College of Medicine, King Saud Bin Abdul-Aziz, University of Health Science, Saudi Arabia
2 King Saud University, Saudi Arabia
3 Security Forces Hospital, Riyadh, Saudi Arabia

Correspondence Address:
Abdullah Al-Shimemeri
Department of ICU-1425, King Fahad Hospital- National Guard, P.O. Box 22490, Riyadh - 11426
Saudi Arabia

Abstract

OBJECTIVE: To evaluate the impact of an extensive education campaign for physicians, in effecting positive changes, in their asthma prescription practice, in line with the «SQ»Saudi protocol for diagnosis and management of asthma«SQ». MATERIALS AND METHODS : An extensive campaign on asthma management for physicians in Saudi Arabia was conducted in 1995-1996, based on the «SQ»Saudi protocol for asthma diagnosis and management«SQ». During this campaign, one day courses-cum-workshops were held in 19 different cities, for over 2500 physicians (8% of all physicians in the kingdom). To evaluate the changes in asthma prescription, we retrospectively reviewed the charts of 98 asthmatic patients in 1994 and 100 patients in 1997, attending the outpatient department of two tertiary care hospitals, with over 500 beds, each in Riyadh and Jeddah. Data on demographic profile of the patients, Pulmonary function test and medications prescribed, were analysed and compared between the two groups. RESULTS: The mean age and severity of asthma was similar in both the groups.The prescription rate of inhaled steroids and inhaled beta-agonists increased significantly, with decrease in the use of oral beta-agonists, oral steroids, Theophylline, sodium cromoglycate and ketotifen. Conclusion: The use of inhaled steroids and inhaled beta agonists, considerably improved after the asthma education campaign for physicians in Saudi Arabia. Education campaign for physicians may be effective and could help in the improvement of clinical practice towards a specific disease.



How to cite this article:
Al-Shimemeri A, Al-Ghadeer H, Giridhar H, Al-Jahdali H, Al-Moamary M, Khan J, Al-Mobeireek A, Al Wazzan A. Impact of an extensive asthma education campaign for physicians on their drug prescription practices.Ann Thorac Med 2006;1:20-25


How to cite this URL:
Al-Shimemeri A, Al-Ghadeer H, Giridhar H, Al-Jahdali H, Al-Moamary M, Khan J, Al-Mobeireek A, Al Wazzan A. Impact of an extensive asthma education campaign for physicians on their drug prescription practices. Ann Thorac Med [serial online] 2006 [cited 2020 Jan 20 ];1:20-25
Available from: http://www.thoracicmedicine.org/text.asp?2006/1/1/19/25866


Full Text

Asthma, a common, chronic inflammatory disorder of the airways, associated with pronounced health and economic consequences, has been identified as one of the five pressing global lung problems.[1] The prevalence and severity of asthma appears to be on the increase, affecting 5-15% of the global population. The prevalence of asthma varies from country to country and ranges from 1.1 to 9.9% in adults. The prevalence of childhood asthma with wheeze and/or wheezy bronchitis, ranges from 9.9 to 33%.[2] There is considerable mortality and morbidity due to asthma,[3],[4] the majority of which is avoidable. The increasing morbidity and mortality has been attributed to factors like delay in asthma diagnosis, overreliance on bronchodilators, underestimation of chronic inflammation of airways leading to underuse of antiinflammatory medications and poor patient education.[5],[6],[7],[8],[9] Similar issues have been highlighted by more recent enquiries.[10],[11],[12] The increased prevalence and greater diagnostic awareness of asthma, has placed increased demands on health care resources. Effective asthma control can minimize the personal, social and economic burdens of asthma.[13] This highlights the importance of unifying the approach to managing this disease and putting efforts together in dealing with it. In Saudi Arabia, it is a common disease of the childhood, with 11.5% children, nationally, having wheeze[14],[15] and 10-15% of school children affected by asthma.[16] In adults, although no studies have yet been done, prevalence is likely to be 5% or more. Various studies have indicated, that the increase in asthma related mortality, has been more marked in older patients (over 55 years) and in children. Several guidelines have been published, outlining the current consensus on asthma treatment.[17],[18] There has been substantial change in the pharmaceutical approach to the management of acute severe asthma, in recent decades. The diverse methods of medical treatment and usages, make it difficult for the primary health care and family physicians, to keep up with the advances in the diagnosis, treatment and follow-up of asthma patients. Failure to follow asthma management guidelines, may result in poor asthma control for many patients. In view of the positive impact in the USA, of the management guidelines for the treatment of asthma published by the National Heart, Lung and Blood Institute,[19],[20] as well as similar guidelines from the UK, Australia and Singapore, the Kingdom of Saudi Arabia set up a National Scientific Committee of Bronchial Asthma. In 1995, this selected group of experts drew up a National Protocol (hereafter referred to as the Saudi Protocol giving a stepwise approach, both stepping up (increasing medications as asthma severity increases) and down (decreasing), for the management of asthma with chart summarizing the recommendations suitable for use in the outpatient clinics, inpatient ward and emergency departments. This protocol was planned as a low-tech too to promote better adherence to asthma guidelines. It presents patient-specific recommendations in a user-friendly format, helps recall the classification of asthma severity in a timely manner, inquires about various triggers and uses step therapy, accurately and confidently. Effective use of the protocol could thus help clinicians in primary care settings, diagnose and manage cases of asthma, achieve better asthma outcomes, reduce emergency room visits and hospitalization and also reduce the limitations on physical activity previously imposed by the condition.

An extensive asthma educational campaign for physicians, was conducted all over the country, using the protocol. The objective of the present study is to determine the effectiveness of this campaign, in effecting changes in drug prescription practices, consistent with the 'Saudi Protocol'.

 Materials and Methods



An extensive campaign on asthma management for physicians all over Saudi Arabia, was conducted in 1995-1996, based on the 'Saudi protocol'. The campaign emphasized

• Anti inflammatory therapy as the most important module of treatment of asthma.(Sodiumcromoglycate, nedocromil sodium, beclamethasone, budesonide, fluticasone, triamcinolone, leukotriene receptor antagonists, etc.)

• Encouraging the use of Inhalation therapy over oral medications, as the former provides more rapid relief and has the same effect with smaller doses and less undesirable systemic effects compared to the latter.[21]

• Prescribing inhaled sodium cromoglycate for children with moderate asthma and inhaled steroids or inhaled nedocromil sodium for adults.

• Ketotifen has no defined role in the management of asthma.

During the campaign, one day' courses-cum-workshops were organised in 19 different cities -2 courses each were held in the capital Riyadh, Jeddah, in the western province and Dammam in eastern province and 1 course in each of the 16 other cities. The programme was attended by over 2500 physicians (8% of the total physicians in the country). The participants comprised mainly of pulmonologists, internists, family medicine physicians and general practitioners. The programme included lectures on the epidemiology, pathophysiology, diagnosis, management of acute and chronic asthma and also, education in asthma. A special novel feature was, workshop with stations on peak expiratory flow rate, modes of medication delivery, action plan management and case studies in asthma,where each physician could develop skills in case management by practical experience and simulated case scenarios.

To evaluate the possible impact of the training, it was proposed to study the asthma prescription practices, before and after the training sessions. We planned to retrospectively review 100 charts, each of asthmatic patients attending the outpatient department of two tertiary care hospitals in 1994 and 1997. The hospitals selected were, the King Fahad National Guard Hospital in Riyadh and the King Khalid National Guard Hospital in Jeddah. The clinics were catering to adult asthmatic patients. There was a separate clinic for the child age group. However, this was not included in the study. The FEV1 value determined by spirometry, was taken as a measure of severity of asthma. Demographic data and data on the drugs prescribed for asthma were recorded in each case. The proportion of patients in each group, for whom specific anti-asthma medication was prescribed, was determined.The corresponding proportion of prescriptions in the two groups, in respect of a particular drug, were conferred. Any difference was considered significant, if the pvalue was less than 0.05. All the drugs for the treatment of asthma were available in the study period.

 Results



A total of 98 patients were studied in in 1994 (Group I) and 100 patients in 1997 (Group II). Information of two patients in group I was not complete and so was excluded. The patient characteristics of the two groups are shown in [Table 1]. The mean age (+SD) of patients in years, in the two groups, did not differ significantly -39.5(+14) years in the first group and 38.5(+18) years in the second. The first group had higher proportion of men (56%), while the converse was the case in the second group (54% women). The severity of asthma was similar in both the groups, reflected by FEV1, which was 82(+19)% and 81(+20)% in the groups I and II, respectively ( P >0.05). [Table 2] shows the medications prescribed in the pre- and post- campaign groups. The majority of patients in Group I were prescribed inhaled beta-agonists (67.4%) and Theophylline (61.2%). The other most commonly prescribed drugs in Group I, were Inhaled steroids (30.6%), oral steroids (20.2%), oral beta-agonists (19.3%), ketotifen (12.3%) and sodium cromoglycate (8.1%). This shows underusage of anti-inflammatory therapy and overreliance on bronchodilators for treatment. A strikingly different picture was seen on analysis of the post-campaign prescriptions. In Group II, prescription pattern changed with respect to the order of frequency of prescribed drugs. There was increased use of inhaled beta-agonists (89%) and inhaled steroids (65%), compared to the pre-campaign period (67.4 and 30.6% respectively). These differences were found statistically significant ( P P P P et al , found that antibiotics were the drug, most commonly prescribed by the primary care physicians, representing 40-63% of the total drug prescriptions in the Asir region, in southern Saudi Arabia,[31] while there is little evidence that bacterial infection is a problem in acute severe exacerbation of asthma. It probably occurs in fewer than 15% of cases.[32],[33] Differences in asthma management between respiratory physicians and general physicians, including the use of steroids, was observed in a survey in the UK.[34] Despite strong evidence, that inhaled corticosteroids are beneficial in treating asthma, a number of small studies suggest a use-rate of only 34-56%. In a study by Yuksel et al in Canada, showed that inhaled corticosteroids were prescribed for only about half of the patients, with an acute attack(low use by high risk patients).[35] A study by Raimondi et al , showed that inhaled steroids were rarely used for maintenance treatment and their doses were less than those usually recommended by the guidelines.[36] Underuse of steroids was also observed in the treatment of acute asthma, in the emergency room, in a study in Jeddah.[37] Also, a similar study on prescribing for childhood asthma in New Zealand, showed very similar results.[38] A higher ratio of inhaled corticosteroids to inhaled bronchodilators (generally referred to as C:B ratio), is a feature regarded as good practice[39] and a potential indicator of prescribing for asthma.[40] In recent years, this ratio has been promoted as a quality marker for asthma treatment and cross-sectional data indicates an inverse association with hospital admissions.[41] This inverse association between hospital admissions and the C:B ratio, has also been confirmed recently, by two studies from the United Kingdom.[42],[43] Regular inhalation of beta-agonists is associated with poorer asthma control and decline in lung function.[44],[45],[46] Phin et al reported wide variations in the treatment of childhood asthma among pediatricians, respiratory physicians and general physicians in Australia.[47] Jobanputra et al , in 1991, showed that, of patients with acute asthma managed by general practitioners (GPs) in the UK, 32% were given oral Theophylline and 38% were given antibiotics.[48] The main role of medical practitioners, is to identify patients, whose respiratory symptoms are caused by asthma and to provide the appropriate management. More effective use of existing therapeutic options, will improve asthma management. By 1992, an international consensus report was adopted,[49] leading to the more recent global strategy initiated by WHO.[50] All the guidelines emphasize, that the inflammatory nature of asthma necessitates specific anti-inflammatory therapy. Despite publication of international guidelines for management of asthma, intercountry prescription practices vary considerably and could be improved.[51] The national asthma attack audit carried out in 1991-1992, by the general practitioners in asthma group (GPIAG), highlighted discrepancies between the care delivered and the British Thoracic Society (BTS) guidelines.[52] In a study by Verleden et al[53] in Belgium, showed that only 37.5% of the patients seemed to be correctly treated, using the Global Initiative for Asthma (GINA) guidelines and concluded that GINA guidelines, seem not to be adequately interpreted and implemented by the GPs. The Saudi Protocol is aimed at achieving the best possible control of asthma, with the least possible side effects from medications. Williamson and associates found that one fifth to one half of primary care practitioners in the United States were not aware of, or were not using new evidence about six common procedures.[54] More comprehensive strategies for effecting changes, have employed workshops as a central focus, for intra-session practice rehearsal[55] or other patient educational and practice reinforcing strategies.[56] The National Asthma Education Program[57] expert panel on the management of asthma, in its guidelines, identifies education as one of four critical components of asthma treatment. Health care professionals form an important group, aimed at curbing the rates of asthma-related morbidity and mortality. Health care professionals need continuing education to stay informed, about the new pharmacologic and behavioural approaches to therapy. Hendricson et al in 1994, have reported the improvement of asthma knowledge scores of pediatric residents, after participation in an asthma education program.[58] Studies from USA have demonstrated significant improvement in acute asthma management by Emergency Room residents, following intervention with short concise asthma education sessions,at minimal efforts and costs.[59],[60] It is noteworthy that in UK, the British guidelines did not appear to have an impact on the clinical practice in an audit, before and one year after implementation.[34] Vernejoux et al ,[61] in France, Thompson,[62] in Newzealand and Armstrong et al ,[63] in United Kingdom, have reported considerable variations, in views and adoption of guidelines by physicians. Legorreta et al[64] from survey of outpatients in US, documented the disparity between the guidelines and asthma care practiced. Unfortunately, many clinicians are unaware of the recent changes, with the science of asthma treatment changing, as rapidly as it has in the recent years. Severity is underestimated, with the result that preventive therapy is underused.[5],[65] One study showed that 74 per-cent of those admitted to the hospital with severe asthma, could have had the admission prevented by different prior care.[66] Surveys of deaths from asthma, have shown that nearly 90 per-cent of cases involve avoidable factors.[67] Care in hospitals has also been shown to be associated with different outcomes, depending upon whether care was by a respiratory specialist, by a generalist, or by a physician, with an interest in another specialty. This may mean up to a tenfold difference in the chances of a patient being readmitted, with a further exacerbation within a short time.[68] Health care is changing constantly and rapidly. The Saudi Council for health specialities in its report, has named coherence between educational activities and work experience, as one of the major challenges facing continuing medical education (CME).[69] The gap between theory and practice in medicine, was recognized a long time ago, but little work has been done to bridge this gap.[70] The majority of the educational provision has little relevance and consequently, its impact on the day-to-day work of doctors is minimal.[71] As a result of this dichotomy, CME does not respond appropriately and timely, to the challenges and changes in health care services. For CME to have a real impact on clinical practice, it has to stem from and build on the actual experience of doctors.[72] Though dissemination of guidelines did improve asthma knowledge, there was some controversy over the efficacy of such guidelines, in improving the current practice of asthma management.[73] The CME provision has to be changed into a more effective way of delivery, which adopts principles of adult learning,and encourages active paticipation of doctors, in defining their needs and evaluating CME provision.[74],[75] It has been proved effective in our report, as well as with the study group, prior to the Asthma campaign using the Saudi national protocol, that physician prescription practices showed more use of oral beta-agonists and oral steroids and lesser use of inhaed agents and overuse of sodium cromoglycate, theophylline and ketotifen. This is not in conformity with the recommended practice, as indicated in the guidelines. Following the campaign, which included both lectures on the guidelines and practical workshop with stations and case studies, the physicians' prescriptions showed significantly increased use of inhaled than oral medications, anti-inflammatory medications were the mainstay drugs in the management of asthma and ketotifen prescription reduced to nil, showing that they understood that it has no defined role in the management of asthma. These findings are in confirmity with the Saudi protocol. Thus, CME should be conducted in a way, which helps practicing doctors make their professional work more relevant to and appropriate for, their populations' changing health needs.[76],[77] In a study by Nasser al Haddad et al in Madinah,[73] showed that the average asthma knowledge score increased sharply, just after a program conducted for the diagnosis and management of asthma, followed by gradual decline, evident by a second post-test, repeated eight weeks after the course. Resnic et al ,[78] found that only 10 out of 38 ped house staff physicians (26%) demonstrated perfect technique with a placebo Metered Dose Inhaler (MDI), even when re-evaluated eight weeks after a teaching session and so, repeat education was suggested. Implementing the guidelines on a more local level and using a concise version, has been suggested as possibly more effective.[79],[34],[80] Gorton et al have shown that short concise summaries with freqent reminders, are the best form for dissemination of guidelines.[81] Kibbe et al and Gergen and Goldstein, emphasize that in order for guidelines to be effective in controlling variations in clinical practice, they should be integrated into the total clinical process design, rather than focusing on just physicians (a multidimensional approach).[82],[83] The limitation of this study, is that it was conducted in a tertiary care hospital outpatient department, where the patients are examined by qualified pulmonologists, who have a better knowledge of the disease, as compared to the general practitioners. So we recommend that such studies must be done at the level of general practitioners and family physicians as well, so as to get better feedback of the extensive asthma education campaign.

In conclusion, the pattern of asthma prescription considerably improved, after the asthma educational campaign, targeting physicians in Saudi Arabia. This suggests that such well organised educational campaigns using interactive training approaches for physicians may be effective and could help improve clinical practice towards a specific disease. The Educational campaign should have a coherance between educational activities and work experience. We recommend that these practitioners can be used as facilitators in future training programs for general practitioners, family physicians and primary care physicians. In conclusion, national asthma education program will be beneficial as an initial step, in improving asthma knowledge and increasing awareness in the medical community, on current therapy. In addition, there is need to establish CME programs with emphasis on concise frequent reminders.

References

1Barnes PJ. Is immunotherapy for asthma worthwhile? [editorial]. N Engl J Med 1996;334:531-2.
2Gregg I. Epidemiology. In : TJH Clark, Godfrey S, editors. Asthma. WB Saunders: Philadelphia; 1977. p. 214-40.
3Evans RZ 3rd, Mullaly DI, Wilson WR, Gergen PJ, Rosenberg HM, Grauman JS, et al . National trends in the morbidity and mortality of asthma in the US. Chest 1987;91:455-75.
4Sutherland DC, Beaglehole R, Fenwick J, Jackson RT, Mullins P, Rea HH.Deaths from asthma in Auckland. N Z Med J 1984;97:845-8.
5Gellert AR, Gellert SL, Iliffe SR. Prevalence and management of asthma in a london inner-city general practice. Br J Gen Pract 1990;40:197-201.
6Garret JE, Kolbe J, Richards G, Whitlock T, Rea H. Major reductions in asthma morbidity and mortality in New Zealand. Thorax 1995;50:303-11.
7Henry RL, Fitzclarence CA, Henry DA, Cruickshank D. What do health care professionals know about childhood asthma? J Pediat Child Health 1993;29:32-5.
8Boulet LP, Boutin H, Cote J, Leblanc P, Laviolette M. Evaluation of an asthma self-management educational program. J Asthma 1995;32:199-206.
9Wilson SR, Scamagas P, German DF, Hughes GW, Lulla S, Coss S, et al . A controlled trial of two forms of self-management education for adults with asthma. Am J Med 1993;94:564-74.
10Mohan G, Harrison BD, Badminton RM, Mildenhall S, Wareham NJ. A confidential enquiry into deaths caused by asthma in an English Health region:implications for general practice. Br J Gen Pract 1996;46:529-32.
11Wareham NJ, Harrison BD, Jenkins PF, Nicholls J, Stableforth DE. A district confidential enquiry into deaths due to asthma. Thorax 1993;48:1117-20.
12Sears MR, Rea HH. Patients at risk for dying of asthma: New Zealand experience. J Allerg Clin Immunol 1987;80:477-81.
13Haahtela T. The disease management approach to controlling asthma. Respir Med 2002;96:S1-8.
14Al-Frayh AR, Hasnain SM, Jawadi TQ, Al-Nahdi M. Prevalence of asthma and allergic rhinitis in Saudi Arabia. Allergy and Immunologie. Eur Ann Allerg Clin Immunol 1989;5:16.
15Al-Frayh AR, Hasnain SM, Harfi HA. Respiratory allergy and aeroallergen in Saudi Arabia. J Allerg Clin Immunol 1989;83:198.
16Al-Frayh AR, Bener A, Al Jawadi TQ. Prevalence of asthma among Saudi school children. Saudi Med J 1992;11:448-51.
17Hargreave FE, Dolovich J, Newhouse MT. The assessment of asthma: A conference report. J Allerg Clin Immunol 1990;85:1098-111.
18U.S. Department of Health and Human Services. International Consensus Report on Diagnosis and Management of Asthma. National Heart, Lung and Blood Institute: 1992.
19National Heart, Lung and Blood Institute. Global initiative for asthma. National Institutes of Health: USA; 1995.
20National Heart, Lung and Blood Institute. International consensus report on diagnosis and management of asthma. National Institutes of Health: USA; 1992.
21Webb J, Rees J, Clark TJ. A comparison of effects of different methods of administration of beta 2 sympathomimetics in patients with asthma. Br J Dis Chest 1982;76:351-7.
22British Thoracic Association. Death from asthma in two regions of England. Br Med J 1982;285:1251-5.
23Sears MR, Rea HH, Rothwell RP, O'Donnell TV, Holst PE, Gillies AJ, et al . Asthma mortality: A comparison between New Zealand and England. Br Med J 1986;293:1342-5.
24Sears MR, Rea HH, Fenwick J, Beaglehole R, Gillies AJ, Holst PE, et al . Deaths from asthma in New Zealand. Arch Dis Child 1986;61:6-10.
25Westerman DE, Benatar SR, Potgieter PD, Ferguson AD. Identification of the high risk asthmatic patient. Am J Med 1979;66:565-72.
26Barnes PJ. New drugs for asthma. Eur Respir J 1992;5:1126-36.
27Garret J, Kolbe J, Richards J, Whitlock RH. Major reduction in asthma morbidity and continued reduction in asthma mortality in New Zealand: What lessons have been learned? Thorax 1995;50:303-11.
28Burrows B, Lebowitz MD. The beta agonists dilemma (editorial). N Engl J Med 1992;326:560-1.
29The National scientific Committee of Bronchial Asthma. The National Protocol for the Management of Asthma, The Kingdom of Saudi Arabia Ministry of Health, 2000.
30Mobeireek A, Gee J, Al-Mobeireek K, Al-Majed S, Al-Shimemeri A. Prescribing for asthma in the outpatient clinics in riyadh: Does it follow the guidelines? Ann Saudi Med 1996;16:497-500.
31Ali ME, Ahmed MK. Problems of drug prescription at primary health care center in southern Saudi Arabia. Saudi Med J 1995;213-6.
32Hudgel DW, Langston L Jr, Selner JC, McIntosh K. Viral and bacterial infections in adults with chronic asthma. Am Rev Respir Dis 1979;20:393-7.
33Graham VA, Milton AF, Knowles GK, Davies RJ. Routine antibiotics in hospital managemnet of acute asthma. Lancet 1982;1:418-20.
34Harrison BD, Pearson MG. Audit in acute severe asthma-who benefits? J Roy Coll Physic 1993;27:387-90.
35Yuksel N, Ginther S, Man P, Tsuyuki RT. Underuse of Inhaled corticosteroids in adults with asthma. Pharmacotherapy 2000;20:387-93.
36Raimondi GA. Survey of medical specialists regarding bronchial asthma treatment. Medicine B Aires 1998;58:29-35.
37El-Gamel FM, Kordy MN, Ibrahim MA. A study of acute asthma managemenet in an accident and emergency department. Saudi Med J 1994;15:346-50.
38Thompson R, Dixon F, Watt J, Crane J, Beasley R, Burgess C. Prescribing for Childhood Asthma in the Wellington Area:Comparison with International Guidelines. N Z Med J 1993;106:81-3.
39British Thoracic Society. Guidelines on the management of asthma. Thorax 1993;48:S1-24.
40Audit Commission. A prescription for improvement:towards more rational prescribing in genearl practice. HMSO: London; 1994. p. 26-7.
41Frischer M, Heatlie H, Chapman S, Norwood J, Bashford J, Millson D. Should the corticosteroid to bronchodilator ratio be promoted as a quality prescribing marker? Pub Health 1999;113:247-50.
42Griffiths C, Naish J, Sturdy P, Pereira F. Prescribing and Hospital admissions for asthma in east london. Br Med J 1996;312:481-2.
43Camden and Islington Family Health Services Authority and Health Authority. Asthma in your practice:morbidity, prescribing and hospital admissions. In: Health needs assessment and your general practice. Camden and Islington FHSA ans HA: 1995.
44Sears MR, Taylor DR, Print CG, Lake DC, Li QQ, Flannery EM, et al . Regular inhaled beta agonist treatment in bronchial athma. Lancet 1990;336:1391-6.
45Taylor DR, Sears MR, Herbison GP, Flannery EM, Print CG, Lake DC, et al . Regular Inhaled beta agonist in asthma: Effects on exacerbation and lung function. Thorax 1993;48:134-8.
46van Schayck CP, Dompelling E, Van Herwaarden CL, Folgering H, Verbeek AL, van der Hoogen HJ, et al . Bronchodilator treatment in modern asthma or chronic bronchitis:continuous or on demand? A randomized controlled study. Br Med J 1991;303:1426-31.
47Phin S, Oates RK. Variations in the treatment of childhood asthma. Med J Aust 1993;159:662-6.
48Jobanputra P, Ford A. Management of acute asthma attacks in general practice. Br J Gen Pract 1991;41:410-3.
49International consensus report on diagnosis and treatment of asthma. Eur Respir J 1992;5:601-41.
50Global strategy for asthma management and prevention. NHLBI/WHO report. National Institute of Health: 1993.
51Jepson G, Butler T, Gregory D, Jones K. Prescribing patterns for asthma by general practitioners in six European countries. Respir Med 2000;94:578-83.
52Neville RG, Clark RC, Hoskins G, Smith B. For the GPIAG. National Asthma Attack Audit 1991-1992. Br Med J 1993;306:559-62.
53Verleden GM. De VP. Assessment of asthma severity and treatment by GPs in Belgium: an Asthma Drug Utilization Research study (ADUR). Respir Med 2002;96:170-7.
54Williamson JW, German PS, Weiss R, Skinner EA, Bowes F 3rd. Health science information management and continuing education of physicians: A survey of US primary care practitioners and their opinion leaders. Ann Intern Med 1989;110:151-60.
55Maiman LA, Becker MH, Liptak GS, Nazarian LF, Rounds KA. Improving pediatricians' compliance-enhancing practices: A randomized trial. Am J Dis Child 1988;142:773-9.
56Wilson DM, Taylor W, Gilbert JR, Best JA, Lindsay EA, Willms DG, et al . A randomized trial of a family physician intervention for smoking cessation. JAMA 1988;260:1570-4.
57National Asthma education Program Expert Panel: Guidelines for the diagnosis and management of asthma. 1991;91:1.
58Hendricson WD, Wood PR, Hidalgo HA, Kromer ME, Parcel GS, Ramirez AG. Implementation of a physician education intervention. Arch Pediatr Adolesc Med 1994;148:595-601.
59Lantner RR, Ros SP. Emergency management of asthma in children: Impact of NIH guidelines. Ann Allerg Asthma Immunol 1995;74:188-91.
60Duke T, Kellerman A, Ellis R, Arheart K, Self T. Asthma in the emergency department:impact of a protocol on optimizing therapy. Am J Emerg Med 1991;9:432-5.
61Vernejoux JM, Tunon De Lara JM, Guizard AV, Villanueva P, Taytard A. Moderate asthma in adults: Diagnosis and management in General Medical Practice. Rev Mal Respir 1996;13:499-505.
62Thompson R, Dixon F, Watt J, Crane J, Beasley R, Burgess C. Prescribing for Childhood Asthma in the Wellington Area: Comparison withInternational Guidelines. N Z Med J 1993;106:81-3.
63Armstrong D, Fry J, Armstrong P. General Practitioners' Views of Clinical Guidelines for the Management of Asthma. Int J Qual Health Care 1994;6:199-202.
64Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KM. Compliance with National Asthma Guidelines and Specialty Care. Arch Intern Med 1998;158:457-64.
65Horn CR, Cochrane GM. Management of asthma in general practice. Respir Med 1989;83:67-70.
66Blainey D, Lomas D, Beale A, Partridge M. The cost of acute asthma N how much is preventable? Health Trends 1990;22:151-3.
67British Thoracic Association. Death from asthma in two regions of England. Br Med J 1982;285:1251-5.
68Bucknall CE, Robertson C, Moran F, Stevenson RD. Differences in hospital asthma management. Lancet 1988;1:748-50.
69Ali M, Al-Shehri, Ali I, Al Haqwi, Abdulaziz S. Al Ghamdi, et al . Al Turki Challenges facing continuing medical education and the Saudi Council for Health Specialities. Saudi Med J 2001;22:3-5.
70Schon D. The reflective practitioner: How professionals think in action. Basic Book: New York; 1984.
71Al-Shehri A, Stanley I, Thomas P. Continuing education for general practice. Systematic learning from experience. Br J Gen Pract 1993;43:249-53.
72Stanley I, Al Shehri A, Thomas P. Continuing education for General Practice. Experience, competence and the media of self directed learning for established general practitioners. Br J Gen Pract 1993;43:210-4.
73Al-Haddad N, Al-Ansari SS, Al-Shari AT. Impact of asthma education program on asthma knowledge of general practitioners. Brief report from the Department of Pediatrics, Madinah Maternity and Children Hospital and Family Medicine Program, Ministry of Health: Madinah, Saudi Arabia; 1997.
74Rosenberg W, Donald A. Evidence based medicine; an approach to clinical problem solving. Br Med J 1995;310:1122-6.
75Al-Shehri AM. The Market and Educational Principles in Continuing Medical Education. Postgrad Educ Gen Pract 1994;5:135-42.
76Davis D. Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes. Int J Psychiatr Med 1998;28:21-39.
77Davis DA, Thompson MA, Oxman AD, Haynes RB. Changing physician performance:A systematic review of continuing medical education strategies. JAMA 1995;274:700-5.
78Resnick DJ, Gold RL, Lee-Wong M, Feldman BR, Ramakrishnan R, Davis WJ. Physicians' metered dose inhaler technique after a single teaching session. Ann Allerg Asthma Immunol 1996;76:145-8.
79Pearson MG. Asthma guidelines: Who is guiding whom and where to? Thorax 1993;48:197-8.
80Kips JC, Joos GF, Pauwels RA. Is asthma diagnosis and treatment in general practice altered by specific teaching programs? Eur Resp J 1995;19:2434.
81Gorton TA, Cranford CO, Goldem WE, Walls RC, Pawelak JE. Primary care physicians' response to dissemination of practice guidelines. Arch Fam Med 1995;4:135-92.
82Kibbe DC, Kallzny AD, McLaughlin CP. Integrating guidelines with continuous quality improvement: doing the right thing the right way to achieve the right goals. J Comm J Qual Improv 1994;20:181-91.
83Gergen PJ, Goldstein RA. Does asthma education eqal asthma intervention? Int Arch Allerg Immunol 1995;107:166-8.