Asthma management and morbidity in Australian general practice: the relationship between patient and doctor estimates

Measuring asthma quality in primary care: can we develop better measures?

OBJECTIVE

Asthma is common and commonly under-treated. Currently quality indicators often do not provide specific directions for areas of improvement. This work lays the foundation for a quality improvement initiative that provides practice-specific feedback related directly to clinical activities completed for individual patients with asthma.

METHODS

Medical record review using a group of quality assessment elements developed from previous medical record review studies of asthma care and the NAEPP asthma care guidelines.

RESULTS

For 500 school children ages 5-18 yr who made one or more asthma visits in the year of interest, the frequency of daytime asthma symptoms were recorded in 54% of patients' medical records at any time during a one-year period, while nighttime symptom frequency was recorded in 33%. Only 12% of medical records recorded any information on missed work, school or activity days. Nine percent recorded information or acknowledged any asthma "triggers". Asthma severity level was documented in only an additional 4% of the children's records. Most medical records documented prescribed asthma medications and dosages (85%) but few recorded the medications or dosages the patients were actually taking.

CONCLUSIONS

Many medical records do not include the basic clinical information required to assess asthma severity, adherence to asthma therapy or the response to therapy. This lack of information makes implementation of asthma care guidelines impossible. Therefore, these measures may be useful baseline quality indicators to begin the process of improving asthma care.

How well do doctors know their patients with severe asthma?

BACKGROUND

Rates of asthma mortality have fallen in Australia since the commencement of the National Asthma Campaign and promotion of the Australian asthma management plan. New strategies are now needed to further reduce mortality.

AIM

To examine agreement about key features between asthma patients and their general practitioners (GPs).

METHODS

We interviewed: (i) the next of kin of 56 asthma deaths, (ii) 91 asthma patients presenting to emergency departments with acute severe asthma and (iii) 147 of their GPs.

RESULTS

Agreement was substantial for usage of oral symptomatic medication, but poor for inhaled symptomatic and preventive medications. There was moderate agreement regarding hospital admissions within the last 12 months among the cases, but little about other markers of severity. There was moderate agreement where the presenting or fatal attack was triggered by an upper respiratory-tract infection or aspirin. The next of kin and GPs agreed about family problems, but not about other psychosocial issues. They also agreed about which cases had been given action plans or verbal instructions, but few other aspects of asthma management. There was also moderate agreement regarding the use of peak flow meters by the controls.

CONCLUSIONS

Doctors often have relatively poor insights into self-management practices, social background or trigger factors, even in high-risk patients. This should be considered when planning future campaigns to improve asthma management and further reduce mortality.

A survey on awareness and utilization of new asthma management guidelines in Japan

The present questionnaire survey, designed to interview Japanese internists and pediatricians who were specialists or nonspecialists in allergy or asthma, was conducted to determine the acceptance of "Asthma Prevention and Management Guidelines 1998" 1 year after release. The surveyor visited each physician and used the questionnaire form at the interview. Replies were obtained from a total of 5,963 physicians. The percentage of physicians who were aware of the guidelines was 96% among specialists and 68% among nonspecialists. Among the internists who were aware of the guidelines, the percentage of physicians giving a reply of "I refer to them often" or "I refer to them" in the actual diagnosis and management of asthma was 95% among specialists and 92% among nonspecialists. Therefore, reference was very high. Except for nonspecialists among pediatricians, not less than 60% of physicians expected that propagation of the present guidelines would allow a further decrease in asthma death and further improvement of patient's quality of life. The present survey revealed an increase in guideline awareness over the last several years, which was especially marked in nonspecialists. Furthermore, high reference and high expectancy also verified that physicians recognize the contents of the present guidelines as appropriate.

Funhaler spacer: improving adherence without compromising delivery

A novel asthma spacer device, the "Funhaler", incorporates incentive toys which are isolated from the main inspiratory circuit by a valve. Here we show that its use does not compromise drug delivery. Improved adherence combined with satisfactory delivery characteristics suggest that the Funhaler may be useful for management of young asthmatics.

Prevalence of asthma and asthma action plans in South Australia: population surveys from 1990 to 2001

OBJECTIVES

To assess trends in the prevalence of self-reported doctor-diagnosed asthma, associated asthma related morbidity, and the uptake of written asthma action plans in South Australia, 1990-2001.

DESIGN, SETTING AND PARTICIPANTS

Surveys by telephone interview of the South Australian population between 1990 and 2001, and interview of participants in their own homes by trained health interviewers.

MAIN OUTCOME MEASURES

Asthma prevalence, percentage of patients with written action plans, and asthma associated morbidity.

RESULTS

The reported prevalence of doctor-diagnosed asthma has increased from 8% (95% CI, 6.4%-9.6%) in 1990 to 12.8% (95% CI, 11.4%-14.2%) in 2001. Morbidity, as measured by wakening at night (daily or weekly) and days lost from normal activities because of asthma, has remained constant over the decade. The percentage of patients with written asthma action plans increased to a peak of 42.3% (95% CI, 40.3%-44.3%) in 1995, but then declined to 22.2% (95% CI, 20.7%-23.7%) in 2001.

CONCLUSIONS

The prevalence of asthma has increased while morbidity has remained constant, indicating that the burden of asthma has increased. The associated decline in the percentage of patients with asthma action plans in recent years is cause for concern.

Hospital attendance prediction tool also identifies impaired quality of life in adults with asthma in general practice

STUDY OBJECTIVE

To assess the ability of an adult risk screening questionnaire (RSQ), previously shown to predict attendance at hospital emergency departments, to identify impaired quality of life in adult patients with asthma in general practice.

DESIGN

Baseline data from an RCT of asthma clinics in general practice, using the St. George Respiratory Questionnaire (SGRQ) to measure quality of life.

SETTING

Twelve general practices in Adelaide, Australia.

RESULTS

A total of 184 adult asthmatics were recruited, with a mean (standard deviation) age of 50.3 years (16.6 years). Age, gender, weight, number of comorbidities, smoking status, FEV1 and percent predicted FEV1 (pre-and post-bronchodilator), peak flow (pre and post), and RSQ were independently related to SGRQ scores. After adjusting for potential confounders, an RSQ score predictive of hospital attendance was also associated with an average increase (worsening) in SGRQ total score of 11.9 (95% CI: 7.6, 16.3), an average increase in activity score of 9.0 (2.5, 15.5), symptom score of 14.8 (8.6, 21.0), and impact score of 13.1 (8.6, 17.6). These represent clinically significant differences.

CONCLUSION

An RSQ score predictive of hospital attendance should alert the general practitioner to explore and address symptom, activity, and impact domains associated with impaired quality of life in adult asthma.

National trends in asthma visits and asthma pharmacotherapy, 1978-2002

BACKGROUND

Research is limited on physicians' compliance with recent clinical guidelines for asthma treatment.

OBJECTIVE

Our purpose was to investigate the relationships among clinical guidelines, asthma pharmacotherapy, and office-based visits through use of nationally representative data.

METHODS

Nationally representative data on prescribing patterns by office-based US physicians were extracted from the National Disease and Therapeutic Index. We tracked 1978-2002 trends in the frequency of asthma visits and patterns of asthma pharmacotherapy, focusing on the use of controller and reliever medications.

RESULTS

The estimated annual number of asthma visits in the United States increased continuously from 1978 through 1990 (18 million visits); since 1990, it has remained relatively stable. Controller medication use increased 8-fold between 1978 and 2002, inhaled corticosteroids manifesting the biggest increases. The use of reliever medications, particularly short-acting oral beta(2)-agonists, decreased modestly over this period. The aggregate use of controllers (83% of visits) superseded that of relievers (80%) for the first time in 2001. Improved appropriateness of asthma pharmacotherapy was also suggested by an increase in the controller-to-reliever ratio, which reached 92% in 2002. Xanthines, which once dominated asthma therapy (63% of visits in 1978), were used in only 2% of visits in 2002. More recent drug entrants have been adopted rapidly, single-entity long-acting inhaled beta(2)-agonists being used in 9% of visits and leukotriene modifiers in 24% of visits in 2002.

CONCLUSION

Asthma pharmacotherapy has changed extensively in the past 25 years. Practices over the last decade are increasingly consistent with evidence-based guidelines. These changes in medication use might have contributed to the lack of a recent increase in asthma visits.

Assessment of a medication-based asthma index for population research

Asthma management guidelines recommend the use of preventive medications in sufficient amounts to control asthma symptoms. The validity of a medication use index as a proxy for asthma severity has not been established. We recruited 1,279 Ontario adults with asthma or parents of children with asthma from a community-based surveillance program in 1995-96. Participants completed a telephone questionnaire at baseline, 3 and 6 mo. The questionnaire gathered information about asthma medication use, health care utilization, and symptoms. Asthma was classified as mild in 28%, moderate in 49%, or severe in 23% of patients based on the amount and types of medication used. There were significant differences among groups in health resource use such that adults with higher medication use visited primary care physicians and specialists more frequently, had pulmonary functions tests more frequently, and were admitted to hospital more frequently. The findings among children were similar. There were weak positive correlations between medication use and symptom frequency in adults and children. We conclude that a medication use index may be useful in population-based research where clinical asthma severity data are lacking. Such an index is distinct from but is related to disease control.

Non-compliance in adolescents with chronic lung disease: causative factors and practical approach

Compliance with medical therapies may be considered a challenge in many age groups but especially so in adolescence. The adolescent patient with chronic lung disease may struggle to progress smoothly through the phases of adolescence because of fears of peer rejection and isolation occurring as a result of social, emotional and physical consequences of their underlying lung disease and its treatment. Non-compliance can be viewed as a scale from episodic compliance to frequent compliance with patients moving between ends of the spectrum. Health professionals need to consider the likely degree of compliance with therapies that they recommend, discuss the issue of compliance and the consequences of non-compliance with the adolescent patient and arrive at a workable compromise. This article discusses persistent asthma, cystic fibrosis and advanced neuromuscular disease to illustrate practical approaches to enhancing patient compliance in adolescence.

Assessing pediatric clinical asthma practices and perceptions: a new instrument

Over the past 20 years, the most substantial increases in prevalence, morbidity, and mortality of asthma have been observed among children aged 5-14 years. A survey instrument designed to measure clinical asthma management practices of primary care physicians was developed and evaluated. Study participants included 127 practitioners providing pediatric asthma care in inner-city communities in Baltimore, MD and Washington, DC. Study results found that the instrument assessed four separate dimensions of clinical assessments and five dimensions of physician perceptions. These dimensions should be considered in future research protocols and may be used to design tailored interventions to improve asthma care.

Physician assessments of patient compliance with medical treatment

In a study of how physicians evaluate patient compliance, practitioner judgments were compared to the self-reports of 138 adult patients receiving treatment for pulmonary diseases at an outpatient clinic. The research found no significant relationship between physician evaluations of compliance and accounts given by the same patients. The conclusions of physicians regarding patient compliance proved to be influenced by their views on the seriousness of the condition and the effectiveness of treatments, but patient reports were different. Physicians clearly have difficulties in appraising the compliance behavior of their patients.

Assessing asthma management from interviews of patients and family physicians

Directed self-care is recommended in asthma. Adequate patient education and follow-up are nevertheless necessary to optimize outcomes. We compared the agreement between detailed information on asthma history and management, collected from the patient and the family physician, to validate the files of physicians and to assess patients' knowledge, attitude, and behavior concerning asthma. A sample of 54 asthma patients were interviewed in detail about use of medications and self-care practice; 36 family physicians (FPs) were interviewed concerning asthma therapy, history, and attitudes of the same patients. Forty-eight percent of the patients expressed negative attitudes toward inhaled corticosteroids, for reasons of safety or lack of efficacy. Less than 20% of the patients made regular use of a peak flow meter. Eighty-three percent of the patients usually obtained prescriptions for asthma therapy from their FP, but on average, only 40% of these prescriptions were provided during visits specific to asthma. FPs were not optimally informed of actual treatments and outcomes and had poor perception of patients' attitudes toward treatment. Nonetheless, in about 30% of the patients, FPs identified risk factors for adverse outcome, such as depression and family conflicts. A majority of interviewed patients had a negative perception of anti-inflammatory therapy, specifically relating to issues of safety and efficacy. Peak flow meters were seldom used and therapy was commonly prescribed outside visits specific to asthma. Despite being centrally involved in the care of asthma patients, FP did not optimally assess therapy and outcomes. The findings suggest suboptimal education and health status in this asthma population.