Maximizing Asthma Control

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patient with doctorBy Mark T. O'Hollaren, MD Oregon Health and Science University

In the last several years, the concept of "asthma control" has received significant attention. National and international asthma treatment guidelines increasingly stress the fact that those caring for patients with asthma need to be aware of the impact that asthma has on the daily lives of their patients. Asthma care is moving away from focusing primarily on a number, such as pulmonary function tests or peak expiratory flow measurements, to one in which these numbers are combined with other assessments, such as quality of sleep, limitation of activity and exercise, and requirement for rescue medications.

As with any disease, the choice of an optimal medical program for asthma management is dependent on an accurate assessment of disease severity. There has been much discussion in recent years in regard to the optimal way to diagnose asthma severity at any given point in time. Typically an assessment of asthma severity consists of asking the patient specific questions, such as "How are you doing with your asthma?" We now know that relying on asthma symptoms alone, on the basis of the patients' assessment of their disease control, is an inadequate method of assessing disease severity.[1] It has become clear that patients with asthma, over time, become accustomed to their asthma symptoms, and their asthma baseline may become a "moving target." When asked to assess their own disease, asthma patients are notorious for underestimating the severity of their disease. This underestimation can have dire consequences for patients, with an increasing burden on the healthcare system. If patients underestimate the severity of their disease, it often leads to undertreating their asthma related to medication noncompliance. A more accurate assessment of asthma control requires additional tools to supplement the patient history, with validated, specific (rather than general) questions in regard to the impact of the disease on quality of life. These questions need to be supplemented with objective measures of pulmonary function, with spirometry being the preferred method. Clinicians however, face several key challenges in this arena. First, they must identify methods to optimally and efficiently assess and measure quality of care for patients with a complex disease. Second, they must do so while they are under ever-increasing time pressure to see more patients in less time.

At this year's American College of Allergy, Asthma and Immunology (ACAAI) Annual Meeting, 3 distinguished faculty members presented a series of excellent lectures to try and address some of these issues. They covered 3 distinct but important aspects of asthma control.

First, Bruce Bender, MD, Professor and Head of the Division of Pediatric Behavioral Health at the National Jewish Medical and Research Center in Denver, Colorado, discussed key health-seeking behaviors in patients with asthma. Dr. Bender reviewed several health-related behaviors, including preventive behaviors, adaptive chronic illness behaviors, and risk behaviors -- all of which may affect compliance with a prescribed medical program. His observations on health-related behaviors in youth and adolescence were especially important, and are reviewed in greater detail below.

Andrea Apter, MD, from the University of Pennsylvania, Philadelphia, reviewed different ways in which the clinical and cultural environment may influence asthma outcomes. She reviewed racial and social disparities in healthcare delivery, as well as how some of these differences may affect adherence to a prescribed clinical treatment program.

Finally, Rita Cydulka, MD, Associate Professor and Vice Chair of the Department of Emergency Medicine at Case Western Reserve School of Medicine in Cleveland, Ohio, discussed methods to better establish continuity of care for patients with asthma seen in the emergency department (ED). Her observations in regard to enhancement of care in this unique setting were especially insightful.

Health-Seeking Behaviors in Patients With Asthma

Dr. Bender began by defining several types of health-related behaviors. First, he noted "preventive" health-related behaviors, such as diet, exercise, seat belt use, and seeking out routine medical care. He then discussed "adaptive chronic illness behaviors," which are important when working with a provider to manage chronic illness. These include behaviors, such as communicating with one's provider following a treatment plan, avoiding triggers of a health problem, and taking prescribed medications. Third, he described "risk behaviors," which include smoking, substance abuse, poor diet, inadequate exercise, and unprotected sex. There may be some modulating factors affecting risk behaviors, including cultural and/or socioeconomic factors, health beliefs, or health insurance status.

Asthma and Risk Behavior. The US Centers for Disease Control and Prevention (CDC) conduct an annual survey of youth risk behavior.[2] Dr. Bender pointed out some very interesting findings from the most recent survey. Surprisingly, youths with asthma had a statistically significant higher rate of smoking cigarettes than youths without asthma.[2] Young people with and without asthma had similar rates of healthy behaviors involving diet and exercise.

Do Young People With Asthma Have a Higher Incidence of Depression? The CDC survey showed that asthmatic youths have a statistically higher chance of having considered or attempted suicide in the past 12 months, or having suffered an injury from a suicide attempt in the past 12 months. It is also noteworthy that young people are more likely to smoke if they are depressed. When young people with asthma are also depressed, they are also more likely to participate in binge drinking, or to use marijuana or cocaine.

Dr. Bender also noted that adolescents are less likely to comply with prescribed medication programs than young children, and he cited a number of explanations, including denial, defiance of authority, and the desire for peer acceptance. In addition, he noted that depressed patients are 3 times more likely to be noncompliant with a medical program than patients who are not depressed.[3]

How do you Build Patient Trust? The single, most important factor to increase medication compliance and adherence to treatment plans, Dr. Bender noted, is to build trust between the provider and the patient. It is important to engage them in the conversation and planning stages. Find out what they want, and provide empathy and reassurance. He also stressed that it is very important that you make sure that the key goals of treatment are understood by the patient. Dr. Bender also recommended screening for depression in patients with asthma by asking 2 questions that have been helpful in identifying patients with depression:

  • Have you often been bothered by feeling down, depressed, or hopeless?

  • Have you often been bothered by having little interest or pleasure in doing things?

Dr. Bender noted that youths with asthma smoke more frequently than those without asthma, and they take other health risks at least as frequently as those who do not have asthma. He also noted that depression occurs more often in youth with asthma, and depression may adversely affect compliance with your medication program. He advised depression screening in youth with asthma, and building a treatment program on a foundation of trust between the physician and the patient to improve compliance and the patient's quality of life.

How Does the Clinical Environment Influence Asthma Outcomes?

Dr. Apter began by noting that adherence to a prescribed treatment program is a marker of success of a healthcare delivery system. She also noted that because we live in a society that is increasingly diverse, racial, ethnic, and cultural factors may play a role in the success of a medical intervention that is designed to improve health. In order to be successful, these factors must be taken into consideration.

In the United States, blacks have a higher asthma hospitalization and mortality rate compared with whites. This may be multifactorial in origin. Some have suggested that physician biases may play a role in the delivery of care. For example, Haas and colleagues[4] noted that those of higher socioeconomic status, higher attained educational status, and white race had a higher level of ambulatory treatment intensity (ie, arrangement for a specialist appointment, prescription of an inhaled corticosteroid (ICS), and provision of a peak flow meter) following hospital discharge compared with those who were of lower socioeconomic status, had lower attained educational status, and were nonwhite. Others have noted that any stereotypical biases that physicians may have in regard to different ethnicities may be more apparent during times of high pressure to contain costs, and when dealing with issues involving higher cognitive complexity.[5] These factors become important for several reasons. First, successful treatment is highly dependent on adherence to a prescribed treatment program. Second, adherence increases in proportion to the success of the patient-physician interaction. If a patient senses potential biases as described above, then it is likely to adversely affect adherence to treatment. Policies that help address cultural aspects of care have been shown to result in better medication compliance in minority children on receiving Medicaid.[6]

Do Patient Perceptions About ICS and Other Asthma Treatments Significantly Affect Compliance?

Many patients believe that they can adequately assess their degree of asthma control on the basis of their perceived symptoms. As noted above, the data do not support this notion. Asthma needs to be followed through validated means of assessment, such as spirometry as well as validated questions in regard to control of the disease. Patients may also have unreasonable fears about asthma medications, particularly those in the corticosteroid class. They may mistakenly believe that medications, such as ICS, may cause them to "bulk up" with muscle mass, ie, similar to the effects seen with anabolic steroids. They may also believe that ICS may increase their risk for cancer or other significant side effects. They need to be carefully educated that ICS are safe when taken in low-to-moderate doses, and if higher doses are needed, that it is safer to take the medication than take the risks associated with untreated severe asthma. It is important to try and improve the "health literacy" of all of our patients to improve treatment program compliance.

Establishing Continuity of Care in the ED: Management of Asthma

Dr. Cydulka gave a very informative and enlightening presentation with regard to management of asthma in the ED. She offered a glimpse into the life of an ED physician, including insight into the intensity of the disease and barriers to effective care. She also noted that asthma patients requiring ED management are often severe asthmatics, with 20% having required intubation and mechanical ventilation.[7] She also noted that less than 50% of these patients were on any regular asthma controller medications.[7]

Dr. Cydulka strongly advised more intense study of patients with asthma who require ED care, because they may use a disproportionate share of healthcare resources for asthma. She noted that the objectives of emergency management of asthma include:

  • Rapid relief of airflow obstruction;

  • Correction of any hypoxemia;

  • Address the inflammatory component of asthma (eg, with appropriate medications); and

  • Objectively measure the degree of airway obstruction and the response to therapy.

She cautioned that it is often exceedingly difficult for the ED physician to arrange for continuity of care, or to initiate appropriate long-term environmental controls and chronic medication programs. She did state, however, that the ED physician does have a unique opportunity to encourage appropriate follow-up so that these issues may be addressed appropriately soon after discharge from the ED. Dr. Cydulka also noted the constant flux of very ill patients in and out of the ED, and how this may affect the approach to acute exacerbations of chronic diseases. She emphasized how quick, simple, and easy-to-use tools would be helpful for the ED physician caring for patients with asthma. She noted how helpful the Asthma Control Test (ACT) can be, because it is a validated questionnaire that is easy to administer and that has been correlated with forced expiratory volume in 1 second (FEV1), specialist-assessed asthma severity, and specialist-assessed need for a change in asthma therapy. In addition, she suggested more widespread automatic prompts on electronic medical records to aid in standardizing the approach to asthma care in the ED.

She also noted the still dismal results of ED asthma management when it comes to improving the rate at which asthma patients are given a prescription for an ICS (which was 13% at the time of discharge from the ED in one study).[8] She has also had success by engaging patients with computerized asthma education tools and actually scheduling asthma follow-up visits at the time of the ED visit. Finally, she stressed the need for better communication between the ED physician and the physician who will conduct the follow-up appointment for the patient's asthma.

References

  1. Osborne ML, Vollmer WM, Pedula KL, et al. Lack of correlation of symptoms with specialist-assessed long-term asthma severity. Chest. 1999;115:85-91. Abstract
  2. US Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance system. October 4, 2006. Available at: www.cdc.gov/yrbss Accessed December 7, 2006.
  3. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160:2101-2107. Abstract
  4. Haas JS, Cleary PD, Guadagnoli E, et al. The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma. J Gen Intern Med. 1994;9:121-126. Abstract
  5. Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med. 2000;50:813-828. Abstract
  6. Lieu TA, Finkelstein JA, Lozano P, et al. Cultural competence policies and other predictors of asthma care quality for Medicaid-insured children. Pediatrics. 2004;114:e102-e110. Abstract
  7. Camargo CA Jr, Roberts J, Clark S. US emergency department visits for asthma exacerbations between 1992-1998. Program and abstracts of the 3rd Triennial World Asthma Meeting: AAAAI, ACCP, and ATS; July 13-15, 2001; Chicago, Illinois. Abstract 40.
  8. Cydulka RK, Tamayo-Sarver JH, Wolf C, et al. Inadequate follow-up controller medications among patients with asthma who visit the emergency department. Ann Emerg Med. 2005;46:316-322. Abstract
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