Follow these tips to improve patient management and adherence of asthma treatments
More than 9% of U.S. children and 8% of adults have asthma, according to the United States Centers for Disease Control and Prevention (CDC). This equates to approximately 1 in 12 patients, or 25 million people. The number of patients with asthma continues to grow: a 1% increase in prevalence was reported by the American Academy of Asthma Allergy & Immunology (AAAAI) between 2001 and 2009.
Approximately 14.2 million primary care visits and 1.8 million emergency department visits are attributed to asthma. Based on data from the AAAAI, more than half (59%) of children and one-third (33%) of adults who experienced an asthma exacerbation had to miss time at school or work. Children missed an average of 4 days of school, while adults missed 5 days of work.
Costs associated with asthma add up to $56 billion when medical expenses, missed school and work days, and early deaths are totaled, an average of $3,300 spent per patient with asthma annually.
“Asthma continues to be major public health concern with a large financial impact on families, the nation, and our health care system,” says Christopher J. Portier, PhD, director of the CDC’s National Center for Environmental Health and the Agency for Toxic Substances and Disease Registry. “A key component for adults and children is to create and follow an asthma action plan.”
Because asthma requires chronic management and is associated with high rates of healthcare utilization, the creation of effective patient asthma action plans is an important call to action for primary care physicians.
Patient management tips
Once a patient has been diagnosed with asthma, a chronic disease management model should be followed. Asthma can vary in severity over time, so regular assessment of a patient’s level of functional and objective impairment is necessary. This can include a regular review of symptom severity and the degree to which symptoms are controlled by therapy. This can provide an opportunity to establish whether a patient has required emergency care for an asthma exacerbation, missed school or work, or had limitation of activities since the last visit.
Many asthma symptoms, such as chest tightness, wheezing, cough, shortness of breath, ability to engage in activities, and quality of life, are subjective. Therefore, objective assessments of respiratory function are critical for clinical decision-making. Spirometry, specifically forced expiratory volume in 1 second (FEV1), and its reversibility post-bronchodilation, is the gold standard test for assessing impairment, monitoring treatment effectiveness, and estimating the risk of future asthma events. The use of daily peak flow monitoring is also important, especially in those patients who a poor perception of their symptoms. Peak flow monitoring can enhance compliance while demonstrating improvement with proper adherence. The treatment goal is to maintain normal or near-normal pulmonary function through regular pharmacological treatment and proactive management of exacerbating factors.
In addition to selecting appropriate pharmacological agents, successful treatment includes identifying factors that may exacerbate a patient’s asthma symptoms and providing recommendations to minimize them. These can include:
Using chart reminders or “flags” to identify patients with asthma can help treatment team members quickly see when asthma symptoms should be discussed, even if a patient has come to the office for other reasons. Including an asthma management flow sheet in the patient chart also can help medical staff take a proactive role in measuring FEV1, asking about symptom control, and reminding patients about flu vaccination.
Successful physician-patient communication can help patients better manage their condition and enhance adherence. Because many asthma symptoms are subjective, it is important to allow sufficient time for discussion of symptoms, especially when an asthma exacerbation or its follow-up care is the reason for the visit.
Having the patient or caregiver complete an asthma self-assessment questionnaire, such as the Asthma Control Test, can provide time to evalyate recent asthma control and identify the symptoms he or she wants to discuss. It may also be helpful to have a nursing staff member take extra time to discuss symptoms, review mediciations, and assist with the questionnaire prior to meeting the physician.
ll patients should have a written asthma action plan developed by the patient and provider. Each plan should address symptom severity, appropriate use of medication, and how to identify when emergency care is needed. It should also include information on the patient’s asthma triggers and how to avoid them, along with how and when peak flow monitoring fits into the action plan. The action plan can be used to provide a framework for follow-up appointments.
Patient self-management and self-monitoring are critical components of successful asthma treatment, and education is the key to developing these skills.
At each visit, physicians should confirm that patients and their families are able to recognize symptom patterns, can identify contributing factors and how to avoid them, and learn how to control exacerbations. It is important to review the asthma action plan thoroughly and address any patient questions before the patient leaves the office to ensure clarity concerning guidelines for managing exacerbations, recommendations and techniques for the use of medication, and when emergency medical intervention is necessary. This includes repetitive teaching of skills such as use of metered dose inhalers, spacers, and nebulizers, as well as measuring peak flows.
American Academy of Asthma Allergy & Immunology
Conditions and Treatments: Asthma
American Academy of Family Physicians
Information from Your Family Doctor: How to Treat an Asthma Attack
American Lung Association
Learning More About Asthma
National Institutes of Health
Sample asthma action plan