Changing approaches to asthma management in Australia: effects on asthma morbidity

Health across generations: findings from the Australian Longitudinal Study on Women's Health

Interpretation of changes in health and health care utilization patterns across the life span depends on an understanding of the effects of age, period, and cohort. The purpose of this article is to illustrate differences among three generations of women in demographic factors, health risk factors, and health status indicators from 1996 to 2008. The article examines data from the Australian Longitudinal Study on Women's Health, a broad-ranging project funded by the Australian Government Department of Health and Ageing (DoHA) and involving three age groups of women (born in the periods 1973-1978, 1946-1951, and 1921-1926) who were first surveyed in 1996 and will be surveyed every 3 years until at least 2015. Patterns in selected demographic factors (marital status and level of educational qualification), health risk factors (smoking, alcohol consumption, physical activity, and body mass index [BMI]), and health status indicators (asthma, hypertension, diabetes and depression; physical functioning and mental health scores from the SF-36) were examined to illustrate examples of biological age, generational differences, or period effects that affect all age groups and generations simultaneously. The results can be used to inform the development of responsive and effective models for both prevention and management of chronic disease, including health and aged-care systems that will meet the needs of different generations of women across their life span.

Readmission and survival following hospitalization for chronic obstructive pulmonary disease: long-term trends

BACKGROUND

Exacerbations requiring hospital admission for chronic obstructive pulmonary disease (COPD) contribute to a decline in health status and are costly to the community. Long-term trends in admissions and associated outcomes are difficult to establish because of frequent readmissions, high case fatality and potential diagnostic transfer between COPD and asthma. The Western Australian Data Linkage System provides a unique opportunity to examine admissions for patients with COPD over the long term.

METHOD

Nineteen years of hospital morbidity data, based on International Classification of Diseases-9 criteria were extracted from the Western Australian Data Linkage System (1980-1998) and merged with mortality records to examine trends in hospital admissions for COPD.

RESULTS

The rate of hospital admissions for COPD has declined overall and the rate of first presentation declined in men and remained constant in women. The risk of readmission increased throughout the period (P < 0.0001) and more than half of all admissions were followed by readmission within a year. Median survival following first admission was 6 years (men 5 years; women 8 years). Age, sex and International Classification of Diseases subcategory each showed an independent effect on the risk of mortality (P < 0.0001). The poorest survival was in patients subcategorized as emphysema. For patients with multiple admissions, the likelihood of cross-over between COPD and asthma was high and increased with the total number of admissions.

CONCLUSION

The rate of admission for COPD has declined in Western Australia; however, the resource burden will continue to increase because of the ageing population. This has policy implications for the development of acute care treatment programmes for COPD.

Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community

BACKGROUND

Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design.

METHODS

Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.

RESULTS

186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from "severe" to "not severe" than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference -149.11 microg, 95% CI -283.87 to -14.36; p=0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting beta agonist (OR 3.80, 95% CI 1.40 to 10.32; p=0.01) and improved scores on risk of non-adherence (difference -0.44, 95% CI -0.69 to -0.18; p=0.04), quality of life (difference -0.23, 95% CI -0.46 to 0.00; p=0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference -1.39, 95% CI -2.44 to -0.35; p<0.01). No significant change in spirometric measures occurred in either group.

CONCLUSIONS

A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.

Estudo comparativo entre o manejo da asma em uma unidade de referência da rede pública de Porto Alegre (RS) e as proposições do III Consenso Brasileiro no Manejo da Asma

OBJETIVO: Avaliar se as diretrizes do III Consenso Brasileiro no Manejo da Asma estão sendo aplicadas em uma população de asmáticos em um hospital de referência da rede pública de Porto Alegre (RS). MÉTODOS: Todos os pacientes adultos que iniciaram tratamento entre 1999 e 2002 foram avaliados. O tratamento recebido foi classificado em concordante ou discordante do Consenso. As características clínicas da asma e a freqüência do tratamento por especialista foram comparadas entre os grupos. RESULTADOS: Foram avaliados os prontuários de 357 pacientes, com média de idade de 41 anos, sendo 106 homens (29,7%) e 251 mulheres (70,3%), 33 tabagistas (9,2%). O tratamento foi considerado discordante em 246 pacientes (70%), sendo que, neste grupo, houve ausência de tratamento com corticóide inalatório em pacientes com asma persistente em 174 deles (71%). Volume expiratório forçado no primeiro segundo normal, idade entre doze e dezoito anos e asma intermitente foram observados com maior freqüência entre os pacientes com tratamento concordante (p < 0,01). Tratamento discordante não teve correlação com tratamento por pneumologista, gravidade da asma persistente ou número de visitas à emergência. CONCLUSÃO: A maioria dos pacientes com asma tratados em uma unidade de referência da rede pública em Porto Alegre não faz o tratamento preconizado pelos consensos e o subtratamento com corticóide inalatório é a principal causa de discordância.

The impact of guidelines on long-term asthma care: a study of hospitalised patients in Malta

OBJECTIVE

To compare actual practice to that recommended in asthma guidelines, published in Malta in February 1998, with respect to the management of asthma. These were the first national clinical guidelines to be published locally.

METHOD

A piloted, structured interview was conducted with patients between 14-59 years who were hospitalised with an admission diagnosis of acute asthma. In the case of repeated admissions, only the first interview was considered. All interviews were carried out by either of two clinical pharmacists and lasted about 30 min. The four-year prospective study started in February 1997 (one year before publication of guidelines and aimed at collecting baseline data) and finished in January 2001 (three years after publication of the local guidelines).

MAIN OUTCOME MEASURES

Inhaled steroids on admission. Patient partnership: use of a written self-management plan and home peak flow monitoring. Patient compliance with inhaled steroids.

RESULTS

304 patients (68% females; mean population age 33.9 years SD +/- 13.41) were interviewed over the four-year period. The difference in proportions test (Z-test) was used to analyse the data comparing years 2, 3 and 4 with year 1. No statistical differences were found when comparing the groups for inhaled steroid treatment on admission or availability of a home peak flow meter. Similarly, no differences were found between groups when comparing compliance with inhaled steroids. A statistically significant increase in availability of a self-management plan was found over the study period (3% in year 1; 1% in year 2; 11% in year 3; 9% in year 4), but the overall use of such plans remains disappointingly low.

CONCLUSION

With the exception of an increased use of self-management plans, there appears to be lack of adherence to guidelines with consequent undertreatment of asthma, despite the fact that guidelines were published three years ago. This indicates a need to ensure better dissemination and implementation strategies to promote adherence. It is suggested that the clinical pharmacist is well-placed to promote adherence to guidelines.

Background severity of asthma in children discharged from the emergency department

OBJECTIVE

Attendance at an Emergency Department (ED) with an acute attack of asthma may be indicative of undertreatment of persistent disease. However, many presentations are in children with infrequent episodic asthma. The aim of this study was to characterize the pattern of asthma of children discharged from ED to determine whether there was potential to improve underlying disease control.

METHODOLOGY

This was a cohort study. Three hundred and ten parental caretakers of 1 to 15-year-old children, attended and discharged from an ED with asthma, completed an asthma control questionnaire, an asthma knowledge questionnaire and a caregiver's quality of life questionnaire. Background severity of asthma was classified and medication history was assessed. Also included were those with their first attack of asthma.

RESULTS

One hundred and thirty-two (43%) children had infrequent episodic asthma, 105 (34%) frequent episodic, 40 (13%) persistent asthma and 33 (11%) first attack asthma. Thirty-nine per cent of children were not receiving preventer therapy and this seemed appropriate; 14% of children with frequent episodic and persistent asthma were not receiving appropriate preventer therapy; and a further 34% had frequent symptoms despite receiving preventer therapy.

CONCLUSIONS

We observed deficiencies in use of preventer medications, use of written asthma management plans and lack of parental knowledge in some children with established asthma who presented to an ED. There was also a large number of children who did not have frequent background symptoms or who presented with their first episode.

Bridging the gap between doctors' and patients' expectations of asthma management

OBJECTIVES

To assess the prevalence of asthma symptoms, their impact on daily activities, and perceptions of disease severity among people with asthma.

METHODS

A telephone survey of 699 people with asthma was conducted in 1999 in metropolitan and nonmetropolitan New South Wales, Victoria, and Queensland, Australia.

RESULTS

Forty-two percent of adults and 26% of children reported experiencing asthma symptoms at least every 2-3 days. Thirty-seven percent of adults and 26% of children reported using a reliever more than four times in the previous week. Of those for whom preventer therapy had been prescribed (61% of respondents), 30% of children and 45% of adults did not use their preventer as instructed. A high proportion of respondents reported avoiding physical and social activities because of their asthma, while 75% said asthma generally made them feel tired. Many respondents attributed frustration (61%), irritability (57%), fear (38%), and worry (43%) to their asthma. Only 50% of respondents had been reviewed by a general practitioner for asthma in the past year. Respondents generally underestimated the severity of their asthma, compared with symptom frequencies reported.

CONCLUSIONS

The Living with Asthma Survey suggests that national asthma management goals are not being achieved in a high proportion of patients, with evidence for both underprescribing and underusage of preventer medication. Achieving closer alignment between medical and patient perspectives is an important goal of asthma education and management in order to help bridge the gap between current concepts of best practice and the reality of persistently poor asthma outcomes.

Action plans, self-monitoring and adherence: changing behaviour to promote better self-management

What we know: Patient self-management improves asthma outcomes. The key features of self-management are having a written asthma action plan, monitoring asthma symptoms and seeking regular review. Self-management is an important goal. Doctors can learn how to improve patient self-management. Multiple attitudinal barriers limit adherence to asthma preventers, especially inhaled corticosteroids in children. Appointment reminders improve clinic attendance. Poor adherence with the asthma treatment regimen is common. Simplification of the healthcare regimen is associated with better adherence. What we need to know: What is it about a written action plan that is the key to its effect? Is it mostly useful for managing acute asthma exacerbations or is it also useful for day-to-day management in the longer term? How can broader implementation of action plans be achieved in Australia? How can appointment reminders be incorporated into regular medical care? How can we modify patient attitudinal and knowledge barriers to preventer medication? How can we improve compliance with asthma preventer medication?