The Status of Asthma Control and Asthma Prescribing Practices in the United States: Results of a Large Prospective Asthma Control Survey of Primary Care Practices

ArticleinJournal of Asthma 42(7):529-35 · October 2005with3 Reads
Impact Factor: 1.80 · DOI: 10.1081/JAS-67000 · Source: PubMed
Abstract

Control of asthma symptoms is, unfortunately, not a reality for many people with asthma. Asthma control is an ongoing challenge, requiring a multidisciplinary treatment approach. The National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute published its Guidelines for the Diagnosis and Management of Asthma in 1997, but the extent of implementation of recommendations in physician's practices remains to be determined. We sought to determine if a systematic implementation of the NAEPP practice guidelines would impact physician's treatment decisions for patients with asthma. The Asthma Care Network is a large, national, point-of-care program developed to assist health care providers in the assessment and management of their patients with asthma. Outcome measurements for the program included level of asthma control, activity limitation, sleep disruption, use of rescue medications, use of controller medications, and urgent care services. A total of 4,901 primary care physicians at 2,876 practice sites enrolled more than 60,000 patients. Nearly three fourths of patients reported symptoms consistent with a lack of asthma control (mean 74%, range 69-81%). Approximately 68% of pediatric patients and 78% of adult patients reported limited activities due to asthma in the past week. Sixty-two percent of pediatric patients and 68% of adult patients reported more than two symptomatic days in the past week. Approximately 40% of the patients surveyed were not using controller therapy. The overall percentage of patients reporting uncontrolled asthma who were prescribed a controller medication increased from 60% to 81%, and the use of inhaled corticosteroids containing medications among these patients increased by 52%. As a result of the assessment of the patients' level of asthma control during the office visit, physicians changed their patterns of prescribing controller therapy in patients with uncontrolled asthma.

    • "...t, studies in recent years have shown a remarkably high ratio of poorly controlled asthma121314151617181920212223242526. Although asthma is due to airway inflammation some patients do not respond to an..."
      The treatment of asthma has improved during the last decades, and the mortality rate has drastically dropped. However, despite the availability of effective treatment, studies in recent years have shown a remarkably high ratio of poorly controlled asthma121314151617181920212223242526. Although asthma is due to airway inflammation some patients do not respond to anti-inflammatory therapy272829303132333435. Different causes of this treatment failure have been discussed and different terms have been suggested for the phenomenon: severe asthma, steroid-resistant asthma and problematic and refractory asthma27282931,32,.
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Recent studies have shown a remarkably high frequency of poorly controlled asthma. Several reasons for this treatment failure have been discussed, however, the basic question of whether the diagnosis is always correct has not been considered. Follow-up studies have shown that in many patients asthma cannot be verified despite ongoing symptoms. Mechanisms other than bronchial obstruction may therefore be responsible. The current definition of asthma may also include symptoms that are related to mechanisms other than bronchial obstruction, the clinical hallmark of asthma. Aim: Based on a review of the four cornerstones of asthma - inflammation, hyperresponsiveness, bronchial obstruction and symptoms - the aim was to present some new aspects and suggestions related to the diagnosis of adult non-allergic asthma. Conclusion: Recent studies have indicated that "classic" asthma may sometimes be confused with asthma-like disorders such as airway sensory hyperreactivity, small airways disease, dysfunctional breathing, non-obstructive dyspnea, hyperventilation and vocal cord dysfunction. This confusion may be one explanation for the high proportion of misdiagnosis and treatment failure. The current diagnosis, focusing on bronchial obstruction, may be too "narrow". As there may be common mechanisms a broadening to include also non-obstructive disorders, forming an asthma syndrome, is suggested. Such broadening requires additional diagnostic steps, such as qualitative studies with analysis of reported symptoms, non-effort demanding methods for determining lung function, capsaicin test for revealing airway sensory hyperreactivity, careful evaluation of the therapeutic as well as diagnostic effect of corticosteroids and testing of suggested theories.
    Full-text · Article · Dec 2014 · Journal of Asthma
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    • "...able to poor disease control due to non-adherence to guideline-recommended controller therapies [7,8], over reliance on reliever medication [9] , inadequate monitoring of disease severity and insuffici..."
      Research demonstrates that only a quarter of patients with persistent asthma symptoms take anti-inflammatory medications as recommended by the guidelines [6]. Much of the cost of asthma care is attributable to poor disease control due to non-adherence to guideline-recommended controller therapies [7,8], over reliance on reliever medication [9] , inadequate monitoring of disease severity and insufficient patient education for effective self-management [10]. Similarly, the care provided for patients with COPD in community settings indicates low level of awareness and implementation of guidelines111213, despite the high level of evidence for the efficacy of guideline-based interventions .
    [Show abstract] [Hide abstract] ABSTRACT: The use of computerized clinical decision support systems may improve the diagnosis and ongoing management of chronic diseases, which requires recurrent visits to multiple health professionals, disease and medication monitoring and modification of patient behavior. The aim of this review was to systematically review randomized controlled trials evaluating the effectiveness of computerized clinical decision systems (CCDSS) in the care of people with asthma and COPD. Randomized controlled trials published between 2003 and 2013 were searched using multiple electronic databases Medline, EMBASE, CINAHL, IPA, Informit, PsychINFO, Compendex, and Cochrane Clinical Controlled Trials Register databases. To be included, RCTs had to evaluate the role of the CCDSSs for asthma and/or COPD in primary care. Nineteen studies representing 16 RCTs met our inclusion criteria. The majority of the trials were conducted in patients with asthma. Study quality was generally high. Meta-analysis was not conducted because of methodological and clinical heterogeneity. The use of CCDSS improved asthma and COPD care in 14 of the 19 studies reviewed (74%). Nine of the nineteen studies showed statistically significant (p < 0.05) improvement in the primary outcomes measured. The majority of the studies evaluated health care process measures as their primary outcomes (10/19). Evidence supports the effectiveness of CCDSS in the care of people with asthma. However there is very little information of its use in COPD care. Although there is considerable improvement in the health care process measures and clinical outcomes through the use of CCDSSs, its effects on user workload and efficiency, safety, costs of care, provider and patient satisfaction remain understudied.
    Full-text · Article · Dec 2014 · BMC Pulmonary Medicine
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    • "...ntment. Many studies have shown that asthma controls among many patients are below expectations [3,39,40]. Studies from Europe and North America record a control rate of 24–35%414243. In contrast, asthm..."
      For instance, some of our patients categorised with partial or poor compliance were not regular with their medication; in actuality, this was due to the fact that they had not been dispensed enough of their medication to last until their next appointment. Many studies have shown that asthma controls among many patients are below expectations [3,39,40]. Studies from Europe and North America record a control rate of 24–35%414243. In contrast, asthma control was good in 42% of the patients in this study.
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: The available assessment tools to determine asthma control do not include components assessing factors that may directly affect control. Our aim was to evaluate the relationship between patient compliance, inhaler technique and the level of asthma control. Methods: Scores from the Asthma Control Test, individual inhaler device checklists and a novel questionnaire on the patient's medication regimen were used to measure control, inhaler technique and compliance, respectively, in patients with asthma attending Sultan Qaboos University Hospital, Muscat, Oman during a 3-month period. Results: All of the 218 patients were receiving inhaled steroids, either in combination with long-acting beta agonists (86.2%) or alone. Asthma control was good in 92 (42.2%) patients; with 38 males (50%) and 54 females (38%), respectively (p = 0.059). Compliance and inhaler technique were poor in 40.8% (89) and 18.3% (40) of the patients. 60% (36) of the patients with good and 59.4% (41) with partial compliance had good control while 83.1% (74) with poor compliance had poor control (p < 0.001). Of the 92 patients with good control, 86 (93.5%) exhibited good inhaler techniques. In contrast, 85% (34) of the patients with poor inhaler techniques demonstrated poor control (odds ratio [OR] = 5.3; 95% confidence interval [CI]: 2.05-14.8; p < 0.001). A total of 93.3% (56) with good and 89.9% (62) with partial compliance demonstrated good inhaler techniques (p < 0.001). In patients with good control, 35 (38%) exhibited both good inhaler techniques and compliance and 38 (41.3%) had a good technique and partial compliance. Conclusion: Patients with good inhaler techniques and compliance have better control of their asthma. Asthma control will remain suboptimal unless the reasons for this lack of control are identified, assessed and eliminated. We recommend that inhaler technique assessment and measurements of patient compliance with their prescribed treatments should be considered for inclusion in the current assessment tools.
    Full-text · Article · Dec 2013 · Journal of Asthma
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    • "...ation of primary care and mitigates the risk that regression to the mean bias enriched our results [8, 10, 11]. There was strong internal consistency in our outcomes over time; early improvements were ..."
      Our cohort was recruited from low acuity settings and we demonstrated asthma control levels that aligned with published surveys. This suggests our cohort was a valid representation of primary care and mitigates the risk that regression to the mean bias enriched our results [8, 10, 11]. There was strong internal consistency in our outcomes over time; early improvements were sustained for almost 2 years and across all health outcome measures.
    [Show abstract] [Hide abstract] ABSTRACT: Quality problem International guidelines establish evidence-based standards for asthma care; however, recommendations are often not implemented and many patients do not meet control targets. Initial assessment Regional pilot data demonstrated a knowledge-to-practice gap. Choice of solutions We engineered health system change in a multi-step approach described by the Canadian Institutes of Health Research knowledge translation framework. Implementation Knowledge translation occurred at multiple levels: patient, practice and local health system. A regional administrative infrastructure and inter-disciplinary care teams were developed. The key project deliverable was a guideline-based interdisciplinary asthma management program. Six community organizations, 33 primary care physicians and 519 patients participated. The program operating cost was $290/patient. Evaluation Six guideline-based care elements were implemented, including spirometry measurement, asthma controller therapy, a written self-management action plan and general asthma education, including the inhaler device technique, role of medications and environmental control strategies in 93, 95, 86, 100, 97 and 87% of patients, respectively. Of the total patients 66% were adults, 61% were female, the mean age was 35.7 (SD = ±24.2) years. At baseline 42% had two or more symptoms beyond acceptable limits vs. 17% (P< 0.001) post-intervention; 71% reported urgent/emergent healthcare visits at baseline (2.94 visits/year) vs. 45% (1.45 visits/year) (P< 0.001); 39% reported absenteeism (5.0 days/year) vs. 19% (3.0 days/year) (P< 0.001). The mean follow-up interval was 22 (SD = ±7) months. Lessons learned A knowledge-translation framework can guide multi-level organizational change, facilitate asthma guideline implementation, and improve health outcomes in community primary care practices. Program costs are similar to those of diabetes programs. Program savings offset costs in a ratio of 2.1:1.
    Full-text · Article · Aug 2012 · International Journal for Quality in Health Care
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    • "... Despite the availability of effective therapies, optimal management of asthma remains problematic [2-8]. Much of the cost of asthma care is attributable to poor disease control due to non-adherence to..."
      Asthma is a prevalent and costly disease with expenditures in the US alone of $648 million annually [1]. Despite the availability of effective therapies, optimal management of asthma remains problematic [2-8]. Much of the cost of asthma care is attributable to poor disease control due to non-adherence to prophylactic therapies, inadequate monitoring of disease severity, and insufficient patient education for effective self-management [1].
    [Show abstract] [Hide abstract] ABSTRACT: Asthma is a prevalent and costly disease resulting in reduced quality of life for a large proportion of individuals. Effective patient self-management is critical for improving health outcomes. However, key aspects of self-management such as self-monitoring of behaviours and symptoms, coupled with regular feedback from the health care team, are rarely addressed or integrated into ongoing care. Health information technology (HIT) provides unique opportunities to facilitate this by providing a means for two way communication and exchange of information between the patient and care team, and access to their health information, presented in personalized ways that can alert them when there is a need for action. The objective of this study is to evaluate the acceptability and efficacy of using a web-based self-management system, My Asthma Portal (MAP), linked to a case-management system on asthma control, and asthma health-related quality of life. The trial is a parallel multi-centered 2-arm pilot randomized controlled trial. Participants are randomly assigned to one of two conditions: a) MAP and usual care; or b) usual care alone. Individuals will be included if they are between 18 and 70, have a confirmed asthma diagnosis, and their asthma is classified as not well controlled by their physician. Asthma control will be evaluated by calculating the amount of fast acting beta agonists recorded as dispensed in the provincial drug database, and asthma quality of life using the Mini Asthma Related Quality of Life Questionnaire. Power calculations indicated a needed total sample size of 80 subjects. Data are collected at baseline, 3, 6, and 9 months post randomization. Recruitment started in March 2010 and the inclusion of patients in the trial in June 2010. Self-management support from the care team is critical for improving chronic disease outcomes. Given the high volume of patients and time constraints during clinical visits, primary care physicians have limited time to teach and reinforce use of proven self-management strategies. HIT has the potential to provide clinicians and a large number of patients with tools to support health behaviour change. Current Controlled Trials ISRCTN34326236.
    Full-text · Article · Dec 2011 · Trials
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    • "...gested that implementing asthma guidelines at the point of care may lead to improved asthma control.9 Nevertheless, there are known gaps between the development and distribution of guidelines and their..."
      Results from an intervention-based asthma assessment and management program suggested that implementing asthma guidelines at the point of care may lead to improved asthma control.9 Nevertheless, there are known gaps between the development and distribution of guidelines and their implementation; in fact, it often takes many years for guidelines to be incorporated into clinical practice.10
    [Show abstract] [Hide abstract] ABSTRACT: Nurse practitioners (NPs) have a unique opportunity as frontline caregivers and patient educators to recognize, assess, and effectively treat the widespread problem of uncontrolled asthma. This review provides a perspective on the role of the NP in implementing the revised National Asthma Education and Prevention Program (NAEPP) Guidelines put forth by the National Heart, Lung, and Blood Institute, thereby helping patients achieve and maintain asthma control. A literature search of PubMed was performed using the terms asthma, nurse practitioner, asthma control, burden, impact, morbidity, mortality, productivity, quality of life, uncontrolled asthma, NAEPP guidelines, assessment, pharmacotherapy, safety. Despite the increased morbidity and mortality and impaired quality of life attributable to uncontrolled asthma, the 2007 NAEPP asthma guidelines are greatly underused. NPs have an opportunity to identify patients at risk and provide enhanced care and education for asthma control. Often, NPs can prescribe medication for and manage these patients, but it is necessary to be able to discern which patients require referral to a specialist.
    Preview · Article · Aug 2011 · Journal of Multidisciplinary Healthcare
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