Asthma management practices in adults--findings from the German Health Update (GEDA) 2010 and the German National Health Interview and Examination Survey (DEGS1) 2008-2011

Low emission zones and population health

Air pollution has a detrimental impact on population health, but the effectiveness of policy measures targeting pollution is underexplored. I exploit the natural experiment generated by the staggered implementation of low emission zones in large cities across Germany to assess their impact on health. Using register data on outpatient and inpatient health care, I find that low emission zones reduce the number of patients with cardiovascular disease by 2-3%. This effect is particularly pronounced for those over the age of 65. The findings suggest that low emission zones can be an effective way to reduce air pollution and improve health.

Implementation of Asthma Management Guidelines and Possible Barriers in Korea

BACKGROUND

There could be a gap between asthma management guidelines and current practice. We evaluated the awareness of and compliance with asthma management guidelines, and the internal and external barriers to compliance, for the first time in Korea.

METHODS

From March to September of 2012, 364 physicians treating asthma patients at primary, secondary, and tertiary teaching hospitals were enrolled. They completed a questionnaire on the awareness of and compliance with asthma management guidelines, and the barriers and alternatives to their implementation.

RESULTS

Of the 364 physicians, 79.1% were men and 56.9% were primary care physicians. The mean age was 40.5 ± 11.2 years. Most of them were aware of asthma management guidelines (89.3%). However, only a portion (11.0%) of them complied with the guidelines for asthma. Pulmonary function tests for diagnosis of asthma were performed by 20.1% of all physicians and 9.2% of primary care physicians, and by 9.9% of all physicians and 5.8% of primary care physicians for monitoring. Physicians stated that 'asthma monitoring' was the most difficult part of the guidelines, followed by 'environmental control and risk factors.' Only 39.6% (31.9% of the primary care physicians) prescribed an inhaled corticosteroid (ICS) as the first-line treatment for persistent asthma. The internal barriers were physician's preference for oral medications, difficulty in use even with inhaler training, and concern over ICS side effects. The external barriers were possible rejection of medical reimbursement by health insurance, refusal by the patient, cost, and a poor environment for teaching the patient how to use the inhaler. Alternatives proposed by physicians to implement asthma management guidelines were to improve medical reimbursement policies and the level of awareness of such guidelines.

CONCLUSION

Compliance with the asthma management guidelines, including ICS prescription, is low despite the awareness of the guidelines. It is necessary to develop a strategy to overcome the internal and external barriers.

Four seasons of Czech asthma study: asthma characteristics and management reality in the Czech Republic

Objective: To describe the characteristics and management of asthma in clinical practice in the Czech Republic in the context of international guidelines and clinical realities.Methods: Data were collected over four seasons from summer 2016 to spring 2017 and are mostly presented using descriptive statistics.Results: We obtained valid data for 4557 adult patients with asthma, including detailed phenotyping (71% eosinophilic allergic, 10% eosinophilic non-allergic, 19% non-eosinophilic non-allergic asthma) from 58 allergologists and 56 pulmonologists. The average time to diagnosis was 3 years. In more than half of the subjects, bronchodilator testing (BDT) results were available at primary diagnosis. More than 10% of physicians did not test for mold allergy. Occupational asthma was diagnosed in 0.7% of subjects. According to the attending physician, 68% of patients had well-controlled and 10% had uncontrolled asthma. Ninety-four percent of patients were on preventive treatment, with 91% using an inhaled corticosteroids (ICS) at an average dose of 705 µg/day budesonide equivalent. Approximately 75% of patients were on an ICS/LABA, with 91% using fixed combinations. Among patients using ICS/formoterol, a maintenance and reliever therapy regime was prescribed in 67%.Conclusions: The quality of asthma management in the Czech Republic is comparable to that of other developed countries and better in some respects (frequent BDT, phenotyping, and use of preventive treatment). Nevertheless, there is unnecessary delay in diagnosis and lack of research on possible environmental causes (workplace, molds). Pharmacotherapy shows good adherence to guidelines. Although 10% of patients show poor control, there is concurrently a trend for overtreatment.

Nationwide use of inhaled corticosteroids by South Korean asthma patients: an examination of the Health Insurance Review and Service database

BACKGROUND

Previous studies have found that the prescription rates of inhaled corticosteroid (ICS) were considerably low although it is recommended as the optimal asthma treatment. The aim of this study was to analyze the current status of ICS prescription for asthma patients in the South Korea.

METHODS

We evaluated quality assessment data based on nationwide Health Insurance Review and Service (HIRA) database from July 2013 to June 2014. ICS prescription rates in asthma patients were analyzed by types and specialty of medical institutions. Also, we graded medical institutions by their ICS prescription rate. In addition, ICS prescription rates were calculated by patient gender, age, and insurance type.

RESULTS

This study included 831,613 patients and 16,804 institutions in the analysis. The overall mean ICS prescription rate was 22.58%. Tertiary hospitals had the highest mean prescription rate (84.16%) whereas primary healthcare clinics had the lowest (20.71%). By specialty, internal medicine physicians prescribed ICS more frequently compared to other specialists. Of all, 47.17% of medical institutions prescribed ICS to <10% of asthma patients, while less than 6% of institutions prescribed ICS to >80% of asthma patients. Also, we found that female and patients with age >90 or <20 years exhibited lower ICS prescription rate.

CONCLUSIONS

The ICS prescription rate was found to be inadequate, given the importance of ICS as an asthma treatment. The prescription rates were especially low in primary healthcare clinics, and by specialists in fields other than internal medicine.

Nationwide pulmonary function test rates in South Korean asthma patients

BACKGROUND

Previous studies have shown that pulmonary function tests (PFTs) are performed at considerably lower rates than would be expected if standard guidelines were followed. The goal of this study was to evaluate the current status of PFT performance in the Republic of Korea.

METHODS

We analysed quality assessment data from a nationwide Health Insurance Review and Assessment Service database collected from July 2013 to June 2014. PFT performance rates were compared among types and specialties of medical institutions. PFT performance rates were also measured by patient gender, age, and insurance type. Possession rates of PFT equipment and performance rates of each type of PFT were also evaluated.

RESULTS

A total of 16,804 institutions and 831,613 patients were included in this study. The mean overall PFT performance rate was 22.67%. The performance rate in tertiary hospitals was 78.00%, while PFTs were performed in only 20.87% of asthma patients at primary health clinics. Male and elderly patients received PFTs more frequently than did female and younger patients. Also, patients who were covered by the Korean Veterans Health Service received a PFT more frequently than those covered by other insurance services. The possession rate of PFT equipment was significantly higher in tertiary hospitals than in primary health clinics. Of all PFT types, spirometry with flow-volume curve was performed for most patients.

CONCLUSIONS

The PFT performance rate was significantly lower than would be expected if guidelines were followed. Average performance rates were higher in tertiary hospitals and for male and elderly patients.

Physician perspectives on the burden and management of asthma in six countries: The Global Asthma Physician Survey (GAPS)

Background

Despite recognition of asthma as a growing global issue and development of global guidelines, asthma treatment practices vary between countries. Several studies have reported patients’ perspectives on asthma control. This study presents physicians’ perspectives and strategies for asthma management.

Methods

Physicians seeing ≥4 adult patients with asthma per month in Australia, Canada, China, France, Germany, and Japan were surveyed (N=1809; ≈300 per country). A standardised questionnaire was developed for this study and administered by telephone, online or face-to-face. Statistics were weighted to account for the sampling scheme.

Results

Physicians estimated that 71% of their adult patients received maintenance medication, with adherence monitored by 76–97% of physicians. Perceived major barriers to patient adherence included: patients taking treatment as needed; acceptance of symptoms; and patients not perceiving treatment benefits. Written action plans (37%) and technology (15%) were seldom employed by physicians to aid patients’ asthma management. Physicians rarely (10%) used validated patient-reported questionnaires to monitor asthma control, instead monitoring selected symptoms, exacerbations, and/or lung function measurements. Awareness of single maintenance and reliever therapy (SMART/MART) varied among countries (56–100%); although most physicians (72%) had prescribed SMART/MART, the majority (91%) co-prescribed a short-acting bronchodilator at least some of the time.

Conclusions

These results show that physicians generally do not employ standardised tools to monitor asthma control or to manage its treatment and that despite high awareness of SMART/MART, the strategy appears to be commonly misapplied. Better education for patients and physicians is required to improve asthma management and resulting patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0492-5) contains supplementary material, which is available to authorized users.

Current status of asthma care in South Korea: nationwide the Health Insurance Review and Assessment Service database

BACKGROUND

Quality control is important for patients with asthma because of its prevalence and because the social burden is substantial. This study analyzed the Health Insurance Review and Assessment Service (HIRA) database to assess asthma quality control in South Korea.

METHODS

We investigated the HIRA nationwide database for reimbursed insurance claims from all medical institutions in South Korea from July 2013 to June 2014. The number of patients with asthma were evaluated and the medical institutions were categorized by type of medical institution. Asthma care quality was assessed by measuring the performance rate on pulmonary function test (PFT) and investigating prescriptions for asthma medications.

RESULTS

A total of 16,804 medical institutions and 831,613 patients were included in this study. Among them, primary health clinics accounted for 87.75% of all medical institutions and 82.50% of patients were treated in a primary health clinic. The overall PFT performance rate was 23.47%, which was highest in tertiary hospitals (80.59%) and relatively lower in primary health clinics (17.06%). Oral agents were prescribed to 93.96% of patients, whereas inhaled agents were prescribed to only 30.34%. Oral corticosteroids were prescribed to 40.61% of patients, leukotriene antagonists to 48.78%, and inhaled corticosteroids (ICS) to 25.37% of patients by drug category.

CONCLUSIONS

Most patients with asthma were treated in primary health clinics rather than higher class medical institutions. Asthma quality control was poor regarding usage of diagnostic measures and prescribed medications.

Internet-based self-management support for adults with asthma: a qualitative study among patients, general practitioners and practice nurses on barriers to implementation

OBJECTIVES

The aim of this study was to explore barriers among patients, general practitioners (GPs) and practice nurses to implement internet-based self-management support as provided by PatientCoach for asthma in primary care.

SETTING

Primary care within South Holland, the Netherlands.

PARTICIPANTS

Twenty-two patients (12 women, mean age 38 years), 21 GPs (6 women, mean age 52 years) and 13 practice nurses (all women, mean age 41 years).

DESIGN

A qualitative study using focus groups and interviews.

OUTCOMES

Barriers as perceived by patients, GPs and practice nurses to implementation of PatientCoach.

METHODS

10 focus groups and 12 interviews were held to collect data: 4 patient focus groups, 4 GP focus groups, 2 practice nurse focus group, 2 patient interviews, 5 GP interviews and 5 practice nurse interviews. A prototype of PatientCoach that included modules for coaching, personalised information, asthma self-monitoring, medication treatment plan, feedback, e-consultations and a forum was demonstrated. A semistructured topic guide was used. Directed content analysis was used to analyse data. Reported barriers were classified according to a framework by Grol and Wensing.

RESULTS

A variety of barriers emerged among all participant groups. Barriers identified among patients include a lack of a patient-professional partnership in using PatientCoach and a lack of perceived benefit in improving asthma symptoms. Barriers identified among GPs include a low sense of urgency towards asthma care and current work routines. Practice nurses identified a low level of structured asthma care and a lack of support by colleagues as barriers. Among all participant groups, insufficient ease of use of PatientCoach, lack of financial arrangements and patient characteristics such as a lack of asthma symptoms were reported as barriers.

CONCLUSIONS

We identified a variety of barriers to implementation of PatientCoach. An effective implementation strategy for internet-based self-management support in asthma care should focus on these barriers.