Studies Show Asthma Management Falls Short of Guidelines
Although national asthma guidelines have been in existence for a decade, health care providers have not widely and consistently used them.1-6 The disconnection has had major effects on asthma patients’ management.
Physicians’ poor adherence to the guidelines appears, in part, to be related to a lack of understanding of the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (EPR-2), published in 1997 by the National Heart, Lung, and Blood Institute’s (NHBLI) National Asthma Education and Prevention Program (NAEPP).
Doerschug and colleagues administered a 31-question multiple-choice test of asthma knowledge based on the EPR-2 to a group of physicians at the University of Iowa.5 Test-takers included asthma specialists, primary care faculty, asthma sub-specialty residents and staff.
The mean total correct score for all physicians was 60 percent, with the asthma specialists scoring slightly higher at 78 percent. However, no group scored at least 65 percent in the category of estimating disease severity; most underestimated disease activity.5
In a random sample of asthma patients receiving care at their institution, the authors reported that contrary to EPR-2, fewer than half of the patients had undergone spirometry testing in the two years prior. In addition, one in five patients were receiving inadequate “step” therapy.5
This is further substantiated by the “Asthma in America” survey conducted in 1998 by Glaxo Wellcome Inc. Researchers polled a national sample of 2,509 adults with asthma or parents of children with asthma, 700 health care providers (including 512 physicians) and 1,000 adults from the general public.6
The survey found 11 percent of physicians caring for asthmatics were unaware of the guidelines. Of those familiar with the guidelines, 32 percent reported that they always followed them, whereas 48 percent said they followed the guidelines most of the time.6
Ninety-two percent of physicians surveyed agreed that anti-inflammatory drugs were essential in the management of persistent asthma. However, although 86 percent of physicians indicated that they would prescribe inhaled corticosteroids for moderate persistent asthma, only 19 percent of patients with persistent asthma reported taking inhaled steroids in the past month.6
The Asthma in America survey also found asthmatic patients underestimated their disease severity, further illustrating the communication gap between physicians and their patients.
Researchers asked subjects about the nature of their asthma symptoms and compared them to symptom severity criteria as defined in EPR-2. Only 22 percent of patients whose symptoms were consistent with severe-persistent asthma actually described their asthma symptoms as severe. Of those asthmatics whose symptoms met the NHLBI criteria for moderate-persistent asthma, only 41 percent described their asthma as moderate or severe.
These same individuals overestimate how well controlled their asthma is; approximately one-third of severe-persistent asthmatics and almost two-thirds of moderate-persistent asthmatics describe their asthma as being “well controlled” or “completely controlled.” Asthma sufferers appear to have resigned themselves to the belief that they should always have some symptoms and/or activity limitations.
Sub-optimal levels of asthma control occur not only with patients living in poverty, but also with those who are managed in certain health maintenance organizations (HMOs).1-4
Legorreta and associates surveyed asthmatics receiving care in an independent physicians’ association-type HMO and noted that 72 percent of respondents with severe disease reported having a steroid inhaler, of whom only 26 percent used it daily.4 Although 26 percent of respondents reported having a peak flow meter, only 16 percent used it on a daily basis.4
In contrast to inhaled corticosteroids and other controller medications, the immediate and noticeable improvement in respiratory symptoms following the use of a short-acting beta-agonist plays a role in the patient’s acceptance of his or her prescribed regimen. Patients tend to use their quick-relief medication at the expense of their long-term controller. Out-of-pocket expenses also may affect this decision on the part of patients.1
Asthmatics also appear to be relatively uninformed that inflammation persists in the airways even in the absence of symptoms. It’s currently hypothesized that this chronic and persistent inflammation may lead to irreversible changes in lung function in susceptible patients, somewhat analogous to cigarette smoking and the risk for COPD. Perhaps better education of this possibility might encourage patients to become more compliant with prescribed therapy, as suggested by the guidelines.
Promoting Optimal Use
The EPR-2 emphasizes that patients are partners with health care providers in their asthma care. Hence, physician and patient education are of paramount importance.
Optimal use of the national asthma guidelines require that health care providers ask specific questions regarding asthma symptoms, rescue beta-agonist use, and activity limitations, and not merely ask generic questions such as, “How is your breathing/asthma?”
However, to ask and follow up on these more detailed questions at each office visit could require considerable time on the part of the practitioner, time that may not be readily available in a busy practice.
Perhaps clinicians can use a checklist, where a health care worker addresses these questions and measures the peak expiratory flow rate. This data can then be included on the front of the patient progress note sheet along with the vital signs. Such a technique might allow the practitioner to better track the medical course of his or her asthmatic patients and more timely adjust the therapeutic regimen when necessary.
Clearly, however, it’s critical that if health care providers are to be expected to perform this education, they must be convinced that implementation of the guidelines would result in better clinical outcomes in their patients. Only then will they be willing to alter their behavior and translate the guidelines into their own clinical practice.
- Gottlieb DJ, Beiser AS, O’Connor GT. Poverty, race, and medication use are correlates of asthma hospitalization rates. Chest. 1995;108:28-35.
- Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management. Arch Intern Med. 1997;157:1193-200.
- Vollmer WM, O’Hollaren M, Ettinger KM, et al. Specialty differences in the management of asthma. Arch Intern Med. 1997;157:1201-8.
- Legorreta AP, Christian-Herman J, O’Connor RD, et al. Compliance with national asthma management guidelines and specialty care. Arch Intern Med. 1998;158:457-64.
- Doerschug KC, Peterson MW, Dayton CS, et al. Asthma guidelines. An assessment of physician understanding and practice. Am J Respir Crit Care Med. 1999;159:1735-41.
- Rickard KA, Stempel DA. Asthma survey demonstrates that the goals of the NHLBI have not been accomplished (abstract). J Allergy Clin Immunol. 1999;103;(1 Pt 2):S171.
Dr. Crim is clinical associate professor of medicine in the division of pulmonary and critical care medicine at the University of North Carolina, Chapel Hill, and principal clinical research physician, North American Medical Affairs-Respiratory, GlaxoSmithKline Inc., Research Triangle Park, N.C.
Communication Gap Between Physicians and Patients
The “Asthma in America” survey found that:
- Although 70 percent of physicians say they use spirometry on an ongoing basis, only 35 percent of asthmatics report having had pulmonary function testing in the past year.
- Eighty-three percent of doctors reported prescribing a peak flow meter, yet only 62 percent of patients ever heard of the device. Twenty-eight percent of asthmatics reported actually having a peak flow meter, but only 9 percent actually use it at least once a week.
- Seventy percent of physicians indicate they prepare an action plan for their asthmatics, but only 27 percent of patients acknowledge having a written action plan.1
- 1. Rickard KA, Stempel DA. Asthma survey demonstrates that the goals of the NHLBI have not been accomplished (abstract). J Allergy Clin Immunol. 1999;103;(1 Pt 2):S171.