Assessing the quality of asthma care provided to Medicaid patients enrolled in managed care organizations in Connecticut

SABA prescriptions and asthma management practices in Singapore: results from a cross-sectional, observational SABINA III study

OBJECTIVES

To evaluate asthma characteristics and treatment patterns, including short-acting β2-agonist (SABA) prescriptions, in primary and specialist care in the Singapore cohort of the SABA use IN Asthma (SABINA III) study.

DESIGN

Cross-sectional, observational study.

SETTING

Multicentre study conducted at five sites across Singapore.

METHODS

In patients with asthma (aged ≥12 years), data on demographics, disease characteristics and asthma treatment prescriptions were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by 2017 Global Initiative for Asthma recommendations) and practice type (primary/specialist care).

RESULTS

Of the 205 patients analysed (mean (SD) age, 53.6 (16.8) years; female, 62%), 55.9% were enrolled by specialists and 44.1% by primary care physicians. Most study patients (80.5%) had moderate-to-severe asthma (86.0% in specialist care and 74.4% in primary care). In the 12 months before study enrolment, 18.0% of patients experienced ≥1 severe exacerbation. Asthma was well or partly controlled in 78.0% of patients. Overall, 17.1% of all patients were overprescribed SABA (≥3 SABA canisters/year) in the preceding 12 months, and overprescription was greater in specialist versus primary care (26.3% vs 5.6%). Only 2.9% of patients were prescribed SABA monotherapy, while 41.0% received SABA in addition to maintenance therapy. Among the latter, 40.5% were overprescribed SABA. Overall, a higher percentage of patients prescribed ≥3 SABA canisters (vs 0-2 SABA canisters) were assessed as having uncontrolled asthma during the study visit (42.9% vs 17.6%). Maintenance therapy in the form of inhaled corticosteroids (ICS) or ICS/long-acting β2 agonist fixed-dose combinations were prescribed to 14.1% and 84.9% of patients, respectively, in the 12 months before enrolment.

CONCLUSIONS

In this Singapore cohort, ~17% of all patients and more than 40% of patients prescribed SABA in addition to maintenance therapy were overprescribed SABA. These findings emphasise the need to align clinical practices with the latest evidence-based treatment recommendations.

TRIAL REGISTRATION

NCT03857178.

Association of Insurance Status with Severity and Management in ED Patients with Asthma Exacerbation

Introduction

Previous studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States.

Methods

We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18–54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge.

Results

The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic severity, those with no insurance were less likely to have guideline-recommended chronic asthma care – i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status.

Conclusion

In this multicenter observational study of ED patients with acute asthma, we found significant discrepancies in chronic asthma severity and management by insurance status. By contrast, there were no differences in acute asthma management among the insurance groups.

Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial

PURPOSE

Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined.

METHODS

In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions.

RESULTS

Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation.

CONCLUSIONS

Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.

Clearing clinical barriers: enhancing social support using a patient navigator for asthma care

BACKGROUND

Patients with moderate or severe asthma, particularly those who are minority or poor, often encounter significant personal, clinical practice, and health system barriers to accessing care.

OBJECTIVE

To explore the ideas of patients and providers for potentially feasible, individualized, cost-effective ways to reduce obstacles to care by providing social support using a patient advocate or navigator.

METHODS

The authors conducted four focus groups of adults with moderate or severe asthma. Participants were recruited from clinics serving low-income and minority urban neighborhoods. Data from these patient focus groups were shared with two additional focus groups, one of nurses and one of physicians. Researchers independently coded and agreed upon themes from all focus groups, which were categorized by types of social support: instrumental (physical aid), informational (educational), emotional (empathizing), validation (comparisons to others).

RESULTS

Patients and providers agreed that a patient navigator could help patients manage asthma by giving social support. Both groups found instrumental and informational support most important. However, patients desired more instrumental help whereas providers focused on informational support. Physicians stressed review of medical information whereas patients wanted information to complete administrative tasks. Providers and patients agreed that the patient navigator's role in asthma would need to address both short-term care of exacerbations and enhance long-term chronic self-management by working with practice personnel.

CONCLUSIONS

Along with medical information, there is a need for providers to connect patients to instrumental support relevant to acute and long-term asthma-self-management.

Group asthma education in a pediatric inpatient setting

Asthma education is an important component of asthma care and management. Children and parents often do not receive asthma education, and frequently, education programs are time consuming. The purpose of this medical record review was to retrospectively determine the impact of a short, group-based, inpatient asthma self-management program on the number of children/parents who received complete asthma education before discharge. The self-management program was instituted in 2006. Participants consisted of all children admitted to a New England children's hospital from January 1, 2005, through December 31, 2006, with a primary diagnosis of asthma. Findings revealed that significantly more (p < .001) children/parents received complete asthma education before discharge in 2006 versus 2005.

Inhaled corticosteroid use in asthmatic children receiving Ohio Medicaid: trend analysis, 1997-2001

BACKGROUND

In 1997, national guidelines emphasized that inhaled corticosteroids (ICSs) are key therapy for individuals with all classes of persistent asthma, including children.

OBJECTIVE

To examine the effect of these guidelines via time-trend analysis of ICS dispensation among children with asthma and Ohio Medicaid insurance.

METHODS

A retrospective cross-sectional analysis by yearly cohorts was performed. From January 1, 1997, to December 31, 2001, all children from birth to the age of 18 years with 6 months of Ohio Medicaid enrollment or more, 1 or more asthma diagnoses associated with a provider claim, and 1 or more prescription claims for an asthma medication in a given calendar year were identified using claims data. The daily beclomethasone equivalent (BME) dose, the daily albuterol equivalent dose, and asthma-related health care use were calculated for each child within each yearly cohort. A time-trend regression analysis of subjects enrolled in all 5 years examined factors associated with BME.

RESULTS

A total of 77,557 children met the study criteria. Among the 1,475 children enrolled during all 5 years, year of enrollment was a positive independent predictor of BME after adjustment for age, race, sex, systemic steroid bursts, albuterol equivalent dose, and health care use (P < .001).

CONCLUSIONS

The daily BME dose significantly increased for children with asthma insured by Ohio Medicaid from 1997 to 2001. However, the percentages of children receiving both ICS and a therapeutic BME dose were alarmingly low. The mean BME dose was particularly low among children with 1 or more emergency department visits, no hospitalizations, and 3 or fewer physician visits for asthma per year, suggesting that broader efforts to target this group are needed.

Insurance status and asthma-related health care utilization in patients with severe asthma

BACKGROUND

Medicaid insurance has been associated with worse asthma outcomes, but the degree to which demographic factors contribute to this relationship has not been well explored.

OBJECTIVE

To evaluate whether insurance status is independently associated with health care utilization (HCU) and asthma control when demographic differences are taken into account.

METHODS

We used baseline data from adults with severe asthma in the Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study. HCU was defined as hospitalization or emergency department visit for asthma in the past 3 months. Asthma control was evaluated using the Asthma Therapy Assessment Questionnaire. Multiple logistic regression was used to compare HCU and asthma control in patients with Medicaid vs those with private health insurance.

RESULTS

Of 1315 patients analyzed, 130 (9.9%) had Medicaid insurance and 1,185 (90.1%) had private insurance. Medicaid insurance was associated with younger age, female sex, race other than white, obesity, active smoking, lower education level, and unemployment. In unadjusted analyses, Medicaid patients had significantly higher HCU (odds ratio [OR], 3.08; 95% confidence interval [CI], 2.11-4.50) and poorer asthma control (OR, 2.56; 95% CI, 1.84-3.57) compared with patients with private insurance. After adjusting for demographic differences, insurance status was no longer associated with HCU (OR, 1.43; 95% CI, 0.92-2.23), and the strength of its association with asthma control was reduced (OR, 1.67; 95% CI, 1.17-2.40).

CONCLUSIONS

Medicaid insurance is not associated with increased HCU in patients with severe asthma once demographic factors have been taken into account but remains modestly associated with poorer asthma control.

Influenza vaccination among children with asthma in medicaid managed care

OBJECTIVE

To describe influenza vaccination rates and identify risk factors for missing vaccination among children with asthma in managed Medicaid.

METHODS

As part of a longitudinal study of asthma care quality, parents of children aged 2-16 years with asthma enrolled in Medicaid managed care organizations in Massachusetts, Washington, and California were surveyed by telephone at baseline and 1 year. We evaluated influenza vaccination rates during the follow-up year.

RESULTS

The study population included 1058 children with asthma. The influenza vaccination rate was 16% among all children with asthma and 21% among those with persistent asthma. Children with persistent asthma (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.36-0.79) and those who had been hospitalized during the follow-up year (OR 0.29, 95% CI 0.11-0.76) were less likely to miss vaccination. Children older than 9 years (OR 1.66, 95% CI 1.13-2.46) and children of parents with less than a high school education (OR 2.29, 95% CI 1.05-5.03), compared with a college degree, were at risk for missing vaccination. Among children with persistent asthma, older children (OR 1.65, 95% CI 1.01-2.69) and children of parents with less than a high school education (OR 4.13, 95% CI 1.43-11.90) were more likely to miss influenza vaccination.

CONCLUSIONS

Our findings suggest that interventions directed toward older children and families with lower educational levels may help improve influenza vaccination rates among this high-risk group. The low overall vaccination rate highlights the need for improvement in this important component of asthma care quality for all children with asthma.

Asthma home teaching: two evaluation approaches

The aim of this research was to measure the impact of home-based teaching on reducing asthma admissions and emergency department (ED) visits for Medicaid-managed care patients utilizing two different study design methods. This was an historical-prospective study utilizing health plan administrative data, including membership files and medical claims. We identified 381 patients aged 2-56 with hospitalizations or ED visits for asthma. These high risk asthma members were recruited for a home-based teaching program to prevent future hospitalizations or ED visits. We evaluated program effectiveness using two quasi-experimental research designs: a "one-group pre/post-test design," where enrolled members served as their own control, and a more rigorous "untreated control group design with pre/post test," where results for enrolled members and a similar control group were compared pre/post test. Poisson regression models were used to investigate the dependence of member rates for asthma-related events on program enrollment, age, sex, race, and geographic region. Using the pre/post test design, members enrolled in the home-based teaching program demonstrated statistically significant reductions in hospital admissions and ED visits (p < 0.001). The untreated control group design, however, found no association between utilization and enrollment in the home-based teaching program (p = 0.510). Small differences were detected for subgroups. A marginally statistically significant impact of the program was found for Whites, but not for Blacks. The quasi-experimental design that utilized an external control group provided an approach that more accurately explained true disease management program impact. In addition, this approach allowed for subgroup analyses to detect opportunities for program improvement.

[Consistency of clinical practice with the scientific evidence in the management of childhood asthma]

INTRODUCTION

There is substantial inconsistency between the evidence available on the management of childhood asthma and its application in practice.

OBJECTIVE

To evaluate the degree of appropriateness of current management of childhood asthma.

MATERIAL AND METHODS

We performed a structured review of the articles published on appropriateness in the recent biomedical literature (last 5 years). Methodological analysis and qualitative synthesis were performed.

RESULTS

Twenty-three articles were identified that reflected the following problems: insufficient documentation on trigger factors, evolution of pulmonary function and symptoms, inadequate guidelines on the treatment of exacerbations, inadequate use of inhaler devices, insufficient use of anti-inflammatory drugs, unjustified heterogeneity in the selection of anti-inflammatory drugs, lack of correlation between severity and level of treatment, lack of written guidelines on customized self-management, unjustified use of antibiotics, and lack of pulmonary function testing devices.

CONCLUSIONS

The management of childhood asthma should be reviewed since a large number of decisions made in clinical practice are not always based on valid scientific evidence.

Asking the correct questions to assess asthma symptoms

A national survey of 896 parents of children with asthma was performed and responses to 2 types of inquiry were compared: global assessment versus specific assessment of symptoms. Almost all parents, 860 (96%), described their child's asthma as under "good control'' when asked a global assessment question. However, 306 (34%)-when asked specific questions-actually described poor asthma control with frequent symptoms. Medicaid insurance (OR: 1.59; 95% CI: 1.03, 2.44) and parental smoking (OR: 1.60; 95% CI: 1.06, 2.43) increased the likelihood that parents' responses would be at risk for misinterpretation. Increased education (OR 0.41: 95% CI: 0.18, 0.91) and English as the primary language (OR 0.39; 95% CI 0.16, 0.96) were associated with decreased likelihood of misinterpretation. Vague, global assessment questions lead to incomplete clinical information and places the patient at risk for inadequate asthma therapy. A better approach is to use specific questions to determine the frequency of daytime or nighttime symptoms.

Underuse of controller medications among children with persistent asthma in the Ohio medicaid population: evolving differences with new medications

BACKGROUND

Despite innovations in asthma care, morbidity and mortality have increased significantly. Underuse of controller medications is a major contributor to increased morbidity and mortality.

OBJECTIVE

To determine the extent of underuse of asthma controller medications among Ohio Medicaid children and to determine if there are racial differences in controller medication claims.

METHODS

We conducted a retrospective analysis of Ohio Medicaid claims data. The source data included all institutional, medical service, and pharmacy claims for fee-for-service patients between January 1, 1997, and December 31, 2001. We identified children with persistent asthma using Health Employer Data Information System criteria. The primary outcome was a controller medication claim. We used multivariable logistic regression to identify risk factors for underutilizing asthma controller medications and applied generalized estimating equations to account for repeated measures.

RESULTS

The proportion of children with claims for a controller medication increased from 53% in 1997 to 67% in 2001. Although there were no racial differences in medication claims in 1997, a smaller proportion of African American children had a claim for a controller medication in 2001 (64.8% vs 67.8%, P < .001). Leukotriene antagonists (LTAs) were driving this difference. Individuals residing in urban areas were significantly less likely to have claims for LTAs when compared with those who resided in nonurban areas.

CONCLUSIONS

Overall use of asthma controller medications among Ohio Medicaid children was poor. There was a widening racial difference in controller medication claims over the 5-year study. Regional differences in LTA claims were driving this racial difference.

Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California

OBJECTIVE

To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics.

METHOD

A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review.

RESULTS

Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors.

CONCLUSION

Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority.

Identification of gaps in the diagnosis and treatment of childhood asthma using a community-based participatory research approach

The goal of this investigation was to use a community-based participatory research approach to develop, pilot test, and administer an asthma screening questionnaire to identify children with asthma and asthma symptoms in a community setting. This study was conducted as the recruitment effort for Community Action Against Asthma, a randomized trial of a household intervention to reduce exposure to environmental triggers of asthma and was not designed as a classic prevalence study. An asthma screening questionnaire was mailed and/or hand delivered to parents of 9,627 children, aged 5 to 11 years, in two geographic areas of Detroit, Michigan, with predominantly African American and Hispanic populations. Additional questionnaires were distributed via community networking. Measurements included parent report of their child's frequency of respiratory symptoms, presence of physician diagnosis of asthma, and frequency of doctor-prescribed asthma medication usage. Among the 3,067 completed questionnaires, 1,570 (51.2% of returned surveys, 16.3% of eligible population) were consistent with asthma of any severity and 398 (12.9% of returned surveys, 4.1% of eligible population) met criteria for moderate-to-severe asthma. Among those meeting criteria for moderate-to-severe asthma, over 30% had not been diagnosed by a physician, over one half were not taking daily asthma medication, and one quarter had not taken any physician-prescribed asthma medication in the past year. Screening surveys conducted within the context of a community-based participatory research partnership can identify large numbers of children with undiagnosed and/or undertreated moderate-to-severe asthma. These children are likely to benefit from interventions to reduce morbidity and improve quality of life.

Use of asthma medication dispensing patterns to predict risk of adverse health outcomes: a study of Medicaid-insured children in managed care programs

BACKGROUND

Regular use of inhaled anti-inflammatory (AI) medication improves outcomes for children with persistent asthma.

OBJECTIVE

To relate 3 measures of asthma medication dispensing to physical health and hospital-based events among children with asthma who were enrolled in 1 of 5 managed care health plans.

METHODS

Parents of Medicaid-insured children with asthma were interviewed at baseline and 1-year follow-up. Utilization data were collected from the health plans in which the children were enrolled. Subjects were stratified into 3 subgroups according to asthma severity: intermittent asthma; persistent asthma for which beta-agonist (BA) medication was dispensed infrequently (< or = 3 times per year); and persistent asthma for which BA medication was dispensed frequently (> or = 4 times per year).

RESULTS

Baseline interviews were completed by 1,663 parents (63% response rate), 1,504 of whom were enrolled in their health plan for at least 11 months during the baseline year. Follow-up interviews were completed by 1,287 (86%) of the 1,504 parents. Among the subgroup of children with persistent asthma for whom BA was dispensed frequently, those who had 1 to 3 AI dispensings had a greater risk for hospital-based events than those with 6 or more AI dispensings. Baseline-year AI medication utilization patterns were not associated with follow-up-year outcomes. No clinically meaningful association was found in subgroups with less severe asthma; however, few AI medications were dispensed to these children.

CONCLUSIONS

Policymakers and clinicians who wish to use medication-based measures to evaluate quality of asthma care should consider counting the number of times AI medication is dispensed among children with more severe asthma.

Variability in asthma care and services for low-income populations among practice sites in managed Medicaid systems

OBJECTIVE

To characterize and describe variability in processes of asthma care and services tailored for low-income populations in practice sites participating in Medicaid managed care (MMC).

STUDY SETTING

Eighty-five practice sites affiliated with five not-for-profit organizations participating in managed Medicaid (three group-model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs]).

STUDY DESIGN/DATA COLLECTION

We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low-income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from "never" to "always"). We report mean and standard deviations of item scores and rankings relative to other items. We used within-MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO.

PRINCIPAL FINDINGS

Processes of care related to asthma varied gready in how often practice sites reported doing them, with information systems and self-management support services ranking lowest. There was also significant variation in the availability of services targeting low-income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site-to-site variation was attributable to the MCO.

CONCLUSIONS

Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self-management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.

Clinical advances in adult asthma

From October 2001 through September 2002, reports of clinical research on asthma in adults focused on the epidemiology of asthma, the investigation of pharmacologic and immunologic therapy in the context of new national guidelines, and discussions of medical economics. Epidemiologic findings include the observation that overall mortality has declined and hospitalizations have remained constant in the United States since 1995, although these rates are at least twice as high in Blacks. Socially and economically disadvantaged groups receive poorer health care for asthma. Young children who have fewer than 5 episodes of wheezing in conjunction with respiratory infections generally have a good prognosis and do not have compromised lung function as adults. Pharmacologic reports and the National Asthma Education and Prevention Program Update recommend low- to medium-dose inhaled steroids combined with a long-acting beta-agonist as the preferred therapy for moderate persistent asthma. The use of chlorofluorocarbon-free medications for asthma is increasing. Medications comprise the largest cost category for asthma.

Relationships between welfare status, health insurance status, and health and medical care among children with asthma

OBJECTIVES

This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma.

METHODS

Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices.

RESULTS

Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured.

CONCLUSIONS

Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.

Understanding and use of inhaler medication by asthmatics in specialty care in Trinidad: a study following development of Caribbean guidelines for asthma management and prevention

STUDY OBJECTIVES

Following the development of the Caribbean Guidelines for Asthma Care, we examined the utilization of inhaled medications in asthmatic patients in Trinidad, West Indies.

SETTING

Chest Clinic, Ministry of Health, Trinidad.

PARTICIPANTS

Physician-diagnosed asthmatic patients who attended the Chest Clinic between July 1998 and August 2000.

MEASUREMENTS AND RESULTS

A consecutive sample of patients who were > 7 years of age (n = 402) was interviewed about compliance with, understanding of, and use of inhaler medication. The inhaler technique of these patients was directly observed. Inhaled steroid therapy was prescribed in 83% of patients but were prescribed the least in elderly patients (63%) and children (62%). Salbutamol was prescribed in 98% of patients, and ipratropium and sodium cromoglycate were selectively prescribed in elderly men and children, respectively. Only 33% of patients used the inhaler correctly, and children and the elderly were the least efficient in its use. The use of a spacer device was advised in 19% of patients, including only 6% of the elderly patients. Explanations for different inhaler therapies were given to 62% of patients, and 53% of patients could describe these reasons. The reported 40% noncompliance rate among patients in the sample was primarily a result of long waiting periods at the pharmacy (58%) and the personal cost incurred on purchasing the medication (52%).

CONCLUSIONS

Educating patients, with a focus on children and the elderly, in inhaler techniques and reinforcing understanding of asthma medications can improve asthma management in Trinidad. Asthma caregivers in the Caribbean should ensure the appropriate dissemination of the guidelines and should outline strategies for their implementation.

Monitoring adherence to the therapy of asthma

Acceptance of current treatment guidelines by physicians and adherence to the recommended clinical regimens by patients are essential for effective asthma therapy. Treatment plans must be based on up-to-date management guidelines and should comprise a strategy for the evaluation and support of patient adherence. Monitoring of adherence with electronic devices enables physicians to base clinical decisions on reliable and objective data. Assessment of prescribing quality should be used to improve treatment of all patients.