Science Feature - May 2005
By Ken Ortolon
All too often, physicians treat illnesses or conditions that could have been prevented, or at least controlled, in the first place. That seems to be true for asthma.
Physicians and public health officials say clinical guidelines for asthma management and a battery of highly effective medications to control the disease and prevent acute attacks could reduce emergency room visits, cut hospitalizations, and improve the quality of life for patients with asthma. But doctors aren't always using the tools they have available to them.
"The strategy for managing asthma is to identify the asthmatic patient early. Those patients having more frequent symptoms or abnormal lung function need to be on a preventative medicine," said Beaumont allergist and immunologist William Fawcett, MD. "But physicians are not prescribing or asthma patients are not taking the preventative medications as often as they should."
That could soon change. The Asthma Coalition of Texas (ACT) was formed more than four years ago by the Texas Department of State Health Services (DSHS), the American Lung Association of Texas, and numerous health professionals and organizations to spread the word that asthma can be effectively controlled.
"Asthma is one of those diseases that have always been around, but in the last three or four years, more attention has been paid nationally to the fact that it is treatable," said Barbara James, RN, director of the Texas Medical Association Science and Quality Department. "We can have improved health, decreased cost, and higher quality of life for the patient if there is adequate treatment."
State health officials say asthma has become more prevalent over the past two decades. According to the Texas Behavioral Risk Factor Survey and Texas inpatient hospital discharge data, there were more than 22,000 asthma-related hospitalizations per year in Texas between 1999 and 2002, with the highest hospitalization rates among children younger than 5 years. And, 822 Texans died from asthma.
As early as 1998, health professionals recognized that asthma management was less than optimal. That year, GlaxoSmithKine funded the Asthma in America survey, which interviewed more than 2,500 adults with asthma and parents of children with asthma, plus 700 health care professionals. The survey concluded that asthma management in America was falling short of the goals set by the National Heart, Lung, and Blood Institute (NHLBI).
The survey also found that although physicians reported following NHLBI guidelines,
- The level of care reported by patients didn't meet current standards;
- There is widespread misunderstanding among patients about the underlying conditions that cause asthma symptoms, as well as confusion about appropriate treatment;
- Poorly controlled asthma symptoms cause hospitalizations, emergency room and urgent care visits, sick days, and limits on activity for asthma sufferers, and
- Greater patient education is needed.
In Texas, Asthma in America found that 92 percent of physicians said anti-inflammatory drugs, such as inhaled steroids, are either "essential or "very important" in long-term management of persistent asthma, but only 19 percent of patients with persistent asthma said they used such medications.
"Patients are receiving incorrect information," said Dr. Fawcett, past president of the Texas Allergy, Asthma, and Immunology Society and an ACT member. He recently saw a patient in his office whose treating physician had recommended using a bronchodilator twice daily and did not prescribe an inhaled steroid or other anti-inflammatory medicine.
That, Dr. Fawcett says, is exactly the wrong approach to asthma management. "An asthmatic should use an inhaled steroid daily to control inflammation. A bronchodilator should be used only for an acute exacerbation of asthma. The regular use of a bronchodilator more than twice a week is considered excessive.
"Better asthma care would increase the prescribing and use of inhaled steroids and other preventative medicines and decrease the use of short-acting bronchodilators," he said.
Unfortunately, even when the controller medications are prescribed, patients often do not understand that the medications need to be taken daily to be effective.
"These medicines are to be taken even when the patient feels good," Dr. Fawcett said. "Currently, many people do not understand this and therefore do not want to take daily medicine. However, for asthmatic patients, this is counterproductive. By failing to manage their disease correctly, they are setting themselves up for an asthma attack."
While busy pediatricians, family physicians, and other primary care doctors may find it difficult to dedicate the time necessary to educate patients on managing their asthma and recognizing warning signs of an oncoming attack, ACT says that is vital in controlling asthma. The group, created as part of a three-year grant DSHS received from the U.S. Centers for Disease Control and Prevention in 2001 for asthma surveillance and planning activities, has produced a statewide asthma action plan.
The plan stresses the need to educate all relevant health care professionals -- including primary care and specialty physicians, nurses, nurse practitioners, and school nurses -- about the evidence-based NHLBI guidelines for asthma care and the need to integrate education into patient care activities. The plan includes strategies for reducing environmental factors that exacerbate asthma, such as tobacco smoke and allergens.
The plan also says children should have access to their asthma medications in school. In 2001, the legislature passed the Texas Inhaler Law to allow children to carry their asthma inhalers to school even if the school has a no-tolerance drug policy.
Susan Bricker, MPH, an epidemiologist with the DSHS Chronic Disease Prevention Branch, says the agency is working on several education campaigns for physicians, school nurses, parents, and patients. They are partnering with managed care organizations to distribute educational materials for physicians on both CD-ROM and as pocket reference guides.
Dr. Fawcett says physicians can greatly improve the quality of asthma care, but they will have to devote the time necessary to really teach their asthma patients about the disease.
"That is the element that I think all of us have difficulty with now because of the dynamics of managed care," he said. "Physicians feel the need to get patients in and out quickly, and you just cannot do that with patients who have a chronic disease. Physicians need a cost-effective way to educate their asthma patients about managing their disease."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
Asthma Resources Available Online
Physicians and asthma patients can find many resources online to help them treat and control asthma.
The National Heart, Lung, and Blood Institute's Guidelines for Diagnosis and Management of Asthma can be found on the institute's Web site at http://www.nhlbi.nih.gov/.
Also, the Asthma Coalition of Texas Web site at www.texasasthma.org has various resources for physicians and other health care professionals, schools, and patients, as well as the 2004 Texas Asthma Plan, an Asthma in Schools Tool Kit, and information on environmental factors that impact asthma.
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