Abstract Rationale Asthma guidelines (GINA 2025, NAEPP 2020) recommend routine spirometry and structured subspecialty follow-up as core elements of high-quality care. These measures are especially critical for patients at high risk for exacerbations, such as those with recent hospitalizations or multiple annual exacerbations. However, adherence to guideline-based evaluation remains inconsistent in real-world practice. Understanding gaps in testing and follow-up is essential todesigning effective quality-improvement (QI) interventions. Methods We conducted a retrospective cohort analysis of 740 adults across a large U.S. health system who were either hospitalized for asthma or experienced ≥2 exacerbations within a calendar year. Patients were stratified by inhaler regimen into three groups: none, SABA-only, or an inhaled-corticosteroid (ICS)-based inhaler. Outcomes included completion of pulmonary function tests (PFTs), methacholine challenge testing, and pulmonology clinic follow-up within 12 months of the index event. Group differences were assessed using chi-square tests, with p 0.05 considered statistically significant. Results The study included 740 high-risk asthma patients (mean age 56 years, 72% female, 77% White). PFT completion differed significantly across inhaler groups: 62.9% in the ICS-based inhaler group, 37.0% in SABA-only users, and 31.5% in those without inhalers (p 0.0001). Pulmonology follow-up demonstrated a similar pattern: 63.7% (controller), 43.0% (SABA-only), and 31.5% (none) (p 0.0001). Methacholine challenge testing was rarely performed (≤2%) and showed no meaningful differences between groups. Overall, despite recent hospitalization or frequent exacerbations, one-third to two-thirds of patients did not undergo spirometry or receive specialty follow-up. Conclusions Our findings highlight a substantial care gap in the evaluation and management of high-risk asthma patients. Many lacked spirometry or specialty follow-up, despite being at elevated risk for poor outcomes. Potential system-level interventions include embedding electronic health record (EHR) prompts and hard stops for spirometry orders and implementing automatic scheduling of post-discharge pulmonology visits. Follow-up healthcare phone after discharge orexacerbations may also reduce these gaps. These approaches could standardize care, improve adherence to guideline-based recommendations, and reduce preventable exacerbations. This abstract is funded by: None
Zafar et al. (Fri,) studied this question.