Level of control and hospital contacts in persistent asthma

Uncontrolled Asthma: Unmet Needs in the Management of Patients

The recent scientific research has provided clinicians with the tools for substantially upgrading the standard of care in the field of bronchial asthma. Nevertheless, satisfactory asthma control still remains an unmet need worldwide. Identifying the major determinants of poor control in different asthma severity levels represents the first step towards the improvement of the overall patients' management. The present review aims to provide an overview of the main unmet needs in asthma control and of the potential tools for overcoming the issue. Implementing a personalized medicine approach is essential, not only in terms of pharmacological treatments, biologic drugs or sophisticated biomarkers. In fact, exploring the complex profile of each patient, from his inflammation phenotype to his preferences and expectations, may help in filling the gap between the big potential of currently available treatments and the overall unsatisfactory asthma control. Telemedicine and e-health technologies may provide a strategy to both optimize disease assessment on a regular basis and enhance patients' empowerment in managing their asthma. Increasing patients' awareness as well as the physicians' knowledge about asthma phenotypes and treatment options besides corticosteroid probably represent the key and more difficult goals of all the players involved in asthma management at every level.

Difference in Asthma Control Test™ (ACT) Scores in Three Different Clinical Practice Settings

Introduction: Asthma control varies in different clinical settings because of its multidimensional and heterogeneous nature, and variability over time. The revised asthma management guidelines indicate that the goal of treatment should be maintaining asthma control for long periods. The aims of this study were to explore: (i) difference in asthma control test scores in patients at different clinical practice settings; (ii) assess if patients were overestimating the level of their asthma control and (iii) assess the relationship of the derived Asthma Control Test (ACT) score to cost of inpatient stay and length of stay (LOS). Materials and Methods: The Asthma Control Test (ACT) is a 5-item questionnaire that assesses the multidimensional perspective of asthma control from activity limitation, shortness of breath, night symptoms, use of rescue medication and self perception of asthma control. The score ranges on a scale from 1 (poorly controlled) to 5 (well controlled). ACT was administered to 447 patients diagnosed with asthma from the in-patient and out-patient settings (new and follow-up cases). Results: Three hundred and ninety-nine (92%) patients completed the ACT questionnaire. The analysis only included patients who had completed the ACT questionnaire. The analysis showed that all the 5 items in the ACT questionnaire were significantly associated with different clinical settings (P <0.001). When we correlated the ACT question 5 (patients self rating of asthma control) in the ACT with Question 3 and Question 4 individually, it showed that most patients did not overestimate their asthma control (P <0.001). However, there was no correlation between the derived ACT score and cost (P = 0.419), LOS (P = 0.373), and the number of comorbid medical history (P = 0.055). Conclusion: Our results reinforce the usefulness of ACT for clinicians to identify patients with poorly controlled asthma and to optimise their level of control in different clinical settings. Key words: Clinical guidelines, Overestimate, Useful

Assessment of asthma control in primary care

OBJECTIVE

To determine the prevalence of uncontrolled asthma in patients who are visiting their primary care provider for any reason.

RESEARCH DESIGN AND METHODS

This multisite, cross-sectional survey was conducted between January 25 and May 2, 2008. Participants aged > or =18 years were recruited from 35 primary care provider sites. Eligible participants presented to the office for any acute medical, routine, follow-up, or nonmedical reason; had a self-reported physician diagnosis of asthma; used medication to treat asthma in the past year; and had no history of COPD. They completed the Asthma Control Test dagger (ACT) and provided information including demographics, health behaviors, medical history, and asthma medication use. Uncontrolled asthma was defined as ACT score < or =19.

RESULTS

The overall weighted prevalence of uncontrolled asthma in 2238 patients in primary care was 58% (95% confidence interval [CI], 0.56-0.60). Among asthma patients seeking care for a respiratory complaint, 72% (95% CI, 0.68-0.75) had uncontrolled asthma compared to 48% (95% CI, 0.45-0.51) of asthma patients presenting for a non-respiratory reason.

CONCLUSIONS

At the population level, over half of patients with asthma under primary care management had uncontrolled asthma at the time of an office visit. Surprisingly, nearly 50% of patients with asthma who presented for office visits not associated with respiratory-related complaints had uncontrolled asthma. The study results may be influenced by a seasonal effect of upper respiratory infections and by the insurance status of the study respondents. However identifying patients with uncontrolled asthma is important and remains a challenge. Therefore, health care providers should consider evaluating asthma control on a regular basis, regardless of reason for visit.

A national audit of the secondary care of "acute" asthma in Wales--February 2006

BACKGROUND

No national audit of acute asthma in secondary care has been undertaken since 1991 in spite of further revisions of national guidelines. There has been no audit of the patient course through the ambulance, accident and emergency units (A&E), medical admission units (MEAU) and in-patient care in an integrated manner.

AIM

To audit the care of acute asthma in the various areas of secondary care in all hospitals in Wales in February 2006.

METHODS

Standardised audit forms were produced to assess ambulance performance during transfer, A&E and MEAU care and in-patient care where admission occurred. The results were compared to national guidelines.

RESULTS

Acute asthma in Wales is a common reason for hospital attendance, 30% of such patients appear to be mild but 19% are severe/acute severe. British Thoracic Society (BTS)/Sign assessment of severity is rarely performed and both monitoring of progress and the discharge process are disappointing. There are major incompatibilities between BTS/Sign guidelines and the current Welsh Ambulance Service protocol. A similar problem exists with the British Society of Accident and Emergency Medicine (BAEM) protocol for moderate asthma.

CONCLUSIONS

This audit demonstrates disappointing adherence to BTS/Sign guidelines for the care of acute asthma. A new approach to acute asthma care in Wales is required.

Impact of patient-related factors on asthma control

BACKGROUND

Patient-related factors are a significant component in the serious public health problem of poor asthma control, yet they have not been extensively studied.

AIMS

To gauge the impact of baseline patient characteristics, compliance and inhaler device manipulation on Asthma Control Score (ACS).

METHODS

ACS (between 0 and 9) was calculated from data recorded in a routine consultation in 4,362 patients with persistent asthma using a maintenance treatment with only inhaled corticosteroid and correlated with patient characteristics, compliance (using 2 methods) and critical errors in inhaler handling.

RESULTS

Mean ASC was 2.95 (95%CI: 2.88-3.02) and asthma control was unsatisfactory (i.e., ACS > or = 4) in 41.1% of subjects, with higher proportions in smokers, non-compliant patients, and those misusing their device. Mean ACS tended to rise with age, and was higher in smokers than in non-smokers (+0.83 point) and ex-smokers (+0.49 point). More than 20% of all subjects were using their inhaler device incorrectly (Turbuhaler 37.1%; Metered-dose inhaler 28.1%; Diskus 21.3%; Aerolizer 7.4%) and this was associated with a 0.84-point increase in ACS. Mean ACS was lower in the most compliant patients (-0.74 points in the 13.4% with a perfect score on a compliance questionnaire) and much lower than in the least compliant (-1.84 points in the 6.6% who reported missing 4 or more doses per week).

CONCLUSION

Patient-related factors including smoking, poor compliance and critical errors in device manipulation, have significant negative impact on asthma control. This could be addressed by patient education.

[Economic aspects of severe asthma]

Severe asthma and difficult-to-treat asthma are major issues in public health, given the mortality and morbidity they induce and their detrimental effects on patients' quality of life. The economic consequences should not be overlooked either. Published studies suggest that asthma-related medical resource use increases with the degree of asthma severity. Medical resource use incurred by severe (and/or difficult-to-treat) asthma could be reduced in part by more appropriate treatment, better patient education, improved coordination of disease management and treatment of comorbid diagnoses. The specific difficulties in the management of severe asthma and/or difficult-to-treat asthma must nonetheless be kept in mind. Recent new treatments appear promising, but their costs and indications in actual medical practice require better definition.

Asthmatic patients' poor awareness of inadequate disease control: a pharmacy-based survey

BACKGROUND

Many asthmatic patients fail to perceive their level of disease control.

OBJECTIVE

To investigate whether patients' ability to identify asthma control varied with personal characteristics or factors related to disease management.

METHODS

Asthmatic patients were consecutively recruited at 348 pharmacies. They completed a questionnaire (regarding personal characteristics and asthma management) linked to pharmacies records of dispensed medications. The Asthma Control Test questionnaire includes 4 dimensions of asthma control (activity limitations, dyspnea, nocturnal awakenings, and rescue medication use) and assesses patients' perception of control ("How would you rate your asthma control during the past 14 days?"). Analyses were restricted to patients with inadequate control. Patients' perception of control was compared across the other dimensions of the questionnaire. The correlates of patients' failure to perceive inadequate asthma control were investigated.

RESULTS

Seven hundred eighteen (68.5%) of the 1,048 patients with inadequate asthma control and documented perception of control considered themselves to be "completely" or "well" controlled. Patients' perception of control did not vary with each dimension of inadequate control. High rates of failure to perceive poor control were observed in patients with at least weekly dyspneas (60%) or nocturnal symptoms (60%). Failure to perceive inadequate control was more likely in patients aged 41 to 50 years (odds ratio, 1.51; 95% confidence interval, 1.05-2.15). No significant effect of factors related to asthma management was observed.

CONCLUSIONS

Patients with most uncontrolled asthma have difficulty in properly perceiving their level of disease control regardless of their personal characteristics or disease management. The reasons for this poor perception should be investigated. Education programs should be created that focus on knowledge of asthma miscontrol criteria.

What are the determinates of asthma control?

The evolution of our understanding of treatment of asthma begins with assessment of severity which is primarily related to the natural history of the disease. Control is defined as normalizing of the physiologic abnormalities and lessening economic and social burden of the disease. This paper reviews the factors that influence the variability and determinants of asthma control. The tools to validate and access asthma control should be employed in daily clinical practice. Therefore, it is important to determine asthma control based on a multidimensional approach including physiologic assessment, global assessment of functionality, daytime symptoms, nighttime symptoms, healthcare utilization, and adherence to therapy.

Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice

The objectives of this study is to compile current knowledge about asthma control in children in relation to goals proposed in international guidelines, to elucidate the factors associated with insufficient asthma control and to address the implications for clinical practice. Review of recent worldwide large population epidemiological surveys and clinical asthma studies of more than 20,000 children are the methods used in this study. The studies report high frequencies of sleep disturbances, emergency visits, school absence and limitations of physical activity due to asthma. Only a small percentage of children with asthma reach the goals of good asthma control set out by Global Initiative for Asthma (GINA). There is evidence of underuse of inhaled corticosteroids even in children with moderate or severe persistent asthma and over-reliance on short-acting beta(2)-agonist rescue medication. Both parents and physicians generally overestimate asthma control and have low expectations about the level of achievable control. Many children with asthma are not being managed in accordance with guideline recommendations, and asthma management practices vary widely between countries. Asthma control falls short of guideline recommendations in large proportions of children with asthma worldwide. Simple methods for assessing asthma control in clinical practice are needed. Treatment goals based on raised expectations should be established in partnership with the asthmatic child and the parents. Effective anti-inflammatory treatment should be used more frequently, and patients should be reviewed regularly.

Quality of asthma care: results from a community pharmacy based survey

BACKGROUND

Optimal control is a major objective of disease management of asthma. The aim of the present study was to provide descriptive data on disease management in asthma patients, including medical resource utilization.

METHODS

Asthma patients (age 18-50 years) were consecutively recruited in 348 dispensing pharmacies. They completed a questionnaire which collected data on personal characteristics, asthma management, including medical resource utilization, including asthma management. Asthma control was measured with the Asthma Control Test. Data from computerized pharmacy records of medications, dispensed before inclusion, were also collected.

RESULTS

In 1791 eligible patients, 1559 accepted to participate in the study (mean age = 36.5, 56.1% of females). During the previous 4 weeks, the asthma control was satisfactory for only 28% of the patients, despite extensive provision of anti-inflammatory asthma control treatments (89%). Combinations of long acting beta agonists (LABA) and inhaled corticosteroids (ICS) were commonly used (59%), while fewer patients received LABA and ICS as two separate medications (15%). In addition, short-acting beta agonists, were frequently dispensed (71%). A substantial number of patients consulted their GPs on a monthly basis. Patients commonly reported daily shortness of breath (30%), daily use of rescue medication (29%) and weekly nocturnal symptoms (32%). Surprisingly, most patients considered their asthma as completely or well controlled (76%).

CONCLUSIONS

Our results clearly identify a need to improve the management of asthma. Education programmes would be beneficial to improve asthma control.

How appropriate is asthma therapy in general practice?

High association between burden of asthma and inadequate disease control make asthma management a major public health issue. We studied asthma management practices of general practitioners (GPs) in France to describe drug therapy and more specifically, to identify correlates of antibiotic prescriptions, a marker of inappropriate asthma management. Patients with persistent asthma aged 17-50 years were evaluated in a 12-month retrospective study using a computerized GPs database (Thales) and a patient survey, in which patients reported hospital contacts, use of oral corticosteroids and recent asthma symptoms. Therapy was described and the correlates of antibiotic prescriptions in the previous year were identified using multivariate logistic regression. During the study period, 16.4% of 1038 patients received one or more prescriptions of theophylline, 31.3% long-acting beta-agonists and 61.6% inhaled corticosteroids. Rates of prescription of antibiotics, expectorants, antihistamines, antitussives and nasal corticosteroids were 57.6, 42.0, 33.0, 19.9, and 14.4%, respectively. In parallel, 15% of patients reported at least one hospital contact for asthma and 43.1% used oral corticosteroids. Antibiotic prescriptions were more likely co-prescribed in patients using expectorants [odds ratio (OR) = 13.0, 95% confidence interval (CI) = 8.5-19.8] and antitussives (OR = 6.5, 95% CI = 3.7-11.6). Moreover, patients using courses of oral corticosteroids, and often visiting their GP (more than four times) during the study period were more likely to receive antibiotics. The results were unchanged when analyses were restricted to non-smokers and younger patients (< or = 40 years). Asthma management was sub-optimal among asthma patients treated by general practitioners in France. Antibiotics, expectorants, antihistamines, antitussives and nasal corticosteroids were commonly prescribed while asthma controllers were under-used.

Correlates of quality of life in patients with asthma

BACKGROUND

Health-related quality of life (HRQOL) is a major outcome in asthma, but the relationships among HRQOL, characteristics of asthma, type of supervision, and sociodemographic characteristics of patients have not been thoroughly explored.

OBJECTIVE

To identify major correlates of HRQOL in a survey of patients with asthma.

METHODS

Patients with asthma were identified by their usual caregivers, either general practitioners or respiratory physicians. In a standardized interview, data were collected on patients' sociodemographic characteristics, medical history, medical resource use in the past 12 months, and asthma QOL. Intensity of asthma therapy was evaluated from the use of inhaled controllers and oral corticosteroids in the past 12 months, and number of asthma attacks during the same period was used as an indicator of level of asthma symptoms.

RESULTS

Ninety-nine patients with asthma were identified (median age, 36 years; 62.6% women). In multivariate analysis, major correlates for lower HRQOL scores were having at least 5 asthma attacks and the number of medical visits in the past 12 months (P < .001 for both). Other significant positive associations were unemployment (P = .01) and female sex (P = .05), but not intensity of therapy, age, or type of asthma supervision (general practitioner vs respiratory physician).

CONCLUSIONS

In this survey, HRQOL scores seem to be primarily related to asthma symptoms, as indicated by the number of attacks experienced by the patients and the frequency of medical contacts in a previous period. The relationships among HRQOL, therapy, and the determinants of control should be investigated in prospective studies.

Process for improving the integration of care across the primary and acute care settings in rural South Australia: asthma as a case study

OBJECTIVE

To develop a process for improving the integration of care across the rural acute and primary care settings using asthma as a case study.

METHODS

Development of the process on the analysis of case note audit, survey, interviews and a workshop.

SETTING

A rural region of South Australia.

RESULTS

A work plan for improving general practitioner (GP)-hospital integration was developed that resulted from analysis of the defined problem, GPs and stakeholder involvement, communication between all stakeholders, provision of an incentive to bring all the stakeholders together, and identification of evidence-based solutions.

CONCLUSIONS

Managing chronic disease in a community requires the integration of care across the primary and acute care setting. To be successful, GP-hospital integration initiatives require stakeholder involvement, locally developed solutions, engagement of GPs, communication and a well-developed plan. This project provides a process for achieving this.

Association between asthma control in children and loss of workdays by caregivers

BACKGROUND

Although the economic burden of pediatric asthma is a significant public health issue, the loss of workdays by caregivers because of their children's asthma remains scarcely investigated.

OBJECTIVES

To evaluate asthma-related loss of workdays incurred by caregivers of asthmatic children and its association with the level of asthma control.

METHODS

A retrospective observational study was conducted based on a French computerized general practitioners' database and a survey questionnaire. Children aged 6 to 16 years with persistent asthma (Global Initiative for Asthma grade > or = 2) were included in the study. Level of children's asthma control was evaluated from recent asthma symptoms. Caregivers reported the number of workdays lost because of their child's asthma during the 12-month study.

RESULTS

Nearly 30% of caregivers lost workdays during the study because of their children's asthma. More than 13% of caregivers lost more than 5 days. Caregiver absenteeism significantly correlated with all components of asthma control (use of relievers, nocturnal symptoms, impairment of activities, and asthma crises). A significant 8-fold risk of losing more than 5 workdays by caregivers was observed when the child's asthma was poorly controlled (odds ratio, 8.6; 95% confidence interval, 2.4-30.5); caregivers' absenteeism also increased significantly with the number of episodes of oral corticosteroid use during the study.

CONCLUSIONS

Caregivers' loss of workdays owing to their children's asthma is substantial and is highly correlated with the level of asthma control. These findings highlight the necessity of educational programs for children with poor asthma control and their caregivers to prevent severe asthma attacks that lead to caregiver absenteeism.