Journal Article - October 2008
By Harold W. Hughes, MD; Sean M. Connery, MS;José O. Rivera, Pharm D; and Manuel Rivera, MD
Dr Hughes, associate professor, and Dr Manuel Rivera, professor, Division of Pulmonary and Critical Medicine, Department of Internal Medicine; Mr. Connery, Department of Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, Texas; and DrJosé Rivera, director and clinical associate professor, UTEP/UT-Austin College of Pharmacy, and assistant dean, UT-Austin College of Pharmacy. Send reprint requests to Harold W. Hughes, MD, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Ave, El Paso, TX 79905; e-mail: Harold.Hughes@ttuhsc.edu.
This publication was made possible by a grant from the Paso del Norte Health Foundation through the Center for Border Health Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Paso del Norte Health Foundation or the Center for Border Health Research.
Over 3 years, we studied the baseline degree of asthma severity and the adequacy of the usual medical management among asthmatics admitted to a large US-Mexican border county hospital. The study design consisted of 2 years of retrospective chart review and 1 year of prospective, semistructured interview collection. Patients were at least 18 years of age and required acute care and hospital admission for asthma exacerbations. The 127 patients studied accounted for 166 hospital admissions for asthma-related primary diagnoses. Most were Hispanic and medically indigent, and only 39% of patients whose asthma severity indicated the use of inhaled corticosteroid medications reported taking them. Most of the hospitalized asthmatic patients studied were on inadequate outpatient medical regimens for the baseline severity of their asthma. Underuse of inhaled corticosteroids was the predominant medication deficiency. Other shortcomings identified in their routine management included a lack of pulmonary function testing, basic asthma education, and treatment by a practitioner qualified in the care of chronic asthma.
Asthma is a relatively common, chronic disease that is estimated to affect more than 14 million Americans and to account annually for 500,000 hospitalizations, 5000 deaths, and approximately $14 billion in costs of medical care and lost productivity. 1 Asthma prevalence and mortality in the United States and Mexico appeared to increase during most of the last two decades. 2,3
The evolution in the United States of evidence-based medical care has led to the establishment of widely accepted asthma management guidelines published by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The National Asthma Education and Prevention Program (NAEPP) introduced the Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma in 1991 (EPR-1) and updated in 1997 (EPR-2), which provide basic recommendations based on expert consensus for the diagnosis and treatment of asthma. 4,5 Despite the refinement of asthma care in the United States over the last decade, such expertise is much less evident in Mexico, and significant differences in the adequacy of diagnosis and treatment may exist in those asthma patients residing in US communities located along the border between the two countries.
The impact of asthma on the US Hispanic population varies with specific heritage and geographic location. Puerto Ricans living in urban areas of the northeast United States have the highest prevalence of asthma in children and highest mortality rates for all ages, while Hispanics of Mexican heritage have rates below those of non-Hispanic whites. 6,7 Prevalence rates for adult asthma in predominantly Hispanic-populated counties in Texas, New Mexico, and California along the US-Mexican border, however, are higher than for surrounding regions. 8
Little is known about the chronic asthma care of adults living in the predominantly Hispanic US-Mexico border region, but the adequacy of chronic asthma management as measured by agreement with NAEPP guidelines has been previously shown to be suboptimal in some at-risk groups. Hispanic children studied at both public and private clinics in Connecticut and Massachusetts were less likely than non-Hispanic children to be prescribed inhaled steroids, and African-Americans in a variety of managed-care settings have been shown to be less likely than whites to receive inhaled steroids and asthma education. 9,10
Access to appropriate medical care in the southwestern border area has been cited as a major regional health concern, aggravated by poverty, language barriers, population mobility, and the tendency of residents to use Mexico's less sophisticated and largely unregulated health care system. 11-13
The primary purpose of this investigation was to apply published national standards to assess asthma severity and the appropriateness of usual outpatient care among asthmatics requiring admission for asthma at a county hospital located in the largest US-Mexico border city. In addition, socioeconomic characteristics of this group were described.
Materials and Methods
The study group included asthmatics requiring hospital admission for exacerbations of asthma. Information obtained from patient encounters, admissions, and individual case information was collected over a 3-year study period for all adult patients admitted with a primary diagnosis of asthma (ICD-9 code series 493.00 through 493.92) 14 to Thomason Hospital in El Paso, Texas. The study group specifically excluded the pediatric population. This hospital is a 346-bed, university-affiliated, acute care facility and is the sole county hospital in the region. Information was collected retrospectively during the first 2 years and in a prospective manner during the final year. Results are reported by each study phase, ie, retrospective or prospective, and as a pooled group to obtain a more accurate representation of this particular patient population.
During the first 2 years, patient data were collected retrospectively through medical records review by using a standardized data collection form to record details commonly available in the hospital chart of an acutely ill asthmatic patient: demographic information, comorbid conditions, asthma symptoms and chronicity, locations and providers of outpatient medical care, outpatient asthma medications, prior hospitalizations for asthma exacerbations, use of tobacco or illicit drugs, occupational history, and funding status. Data were obtained from inpatient medical records that identified an ICD-9 asthma-related primary diagnosis.
Over a 12-month period, study personnel conducted semistructured interviews of asthmatics during their hospitalization. Patients were identified from daily review of emergency department (ED) admission records. The person conducting the interviews was bilingual, had been taught basic patient interviewing skills, and was considered sufficiently knowledgeable in respiratory diseases, specifically asthma, to conduct competent interviews. A data collection form was used to collect not only information similar to that obtained from the retrospective chart analysis but also additional details about patients' asthma history, treatment, and health care utilization. As some patients were admitted several times during the study, the last admission was considered so they were not counted twice. The total number of admissions and total number of hospital days were accounted for by including all admissions from the retrospective and prospective analyses and by pooling all data.
Determination of asthma severity was derived from EPR-2 criteria; patients were classified as having Mild Intermittent, Mild Persistent, Moderate Persistent, or Severe Persistent asthma on the basis of their self-reported chronicity of daytime and nocturnal asthma symptoms, frequency of exacerbations, and pattern of short-acting bronchodilator use. 5 Although measurement of lung function to assess degree of airflow obstruction is included in the EPR-2 criteria, no pulmonary function testing was performed because all patients in the study group were admitted for asthma exacerbations and required acute care. History of pulmonary function testing was considered, and many patients were scheduled for follow-up testing when appropriately stabilized, at which time testing would be more representative of baseline spirometry.
Appropriateness of care was determined by comparing each patient's calculated asthma severity with his or her self-reported usual treatment regimen. Types and patterns of use of all classes of inhaled and oral asthma medications were compared with EPR-2 treatment guidelines corresponding to degree of asthma severity ( Figure ).
The Institutional Review Board of Texas Tech University Health Sciences Center at El Paso and Thomason Hospital approved the study protocol. Informed consent was obtained for patient interviews according to institutional requirements.
Categorical data were analyzed by enumeration and expressed as percentages. Continuous variables are presented as means and standard deviations (SD). The data were analyzed in 3 groups: retrospectively collected data alone, prospectively collected data alone, and as combined data sets where appropriate. All analyses were done by using SPSS statistical software (SPSS, Chicago, IL, version 11.0 for Windows).
Table 1 shows the basic patient demographics for both study periods. The patients were mostly Hispanic and female. Ages averaged 48 years (ranging from 18 to 83 years).
Hospitalization demographics are shown in Table 2 . During the 2-year period with data collected retrospectively, 17 patients had multiple admissions accounting for 47 hospital days, and 45 patients had single admissions accounting for 319 hospital days.
During the prospectively examined year, 69 patients were admitted with an average stay of 3.3 days per admission, totaling 228 hospital days for asthma. Eight patients had multiple admissions accounting for 17 hospital days, and 52 patients had single admissions accounting for 211 hospital days.
For the 3-year pooled period, 166 patient encounters totaled 594 hospital days (35 days in the Intensive Care Unit [ICU]). Twenty-three percent of the total admissions could be attributed to people requiring multiple hospitalizations.
The average length of hospitalizations was in good agreement with the numbers for the data collected from chart records, but the total length was only 366 days for the 2-year retrospective study period (approximately 183 days per year).
Of the 13% of the pooled group initially admitted to the ICU, about one-third required intubation and mechanical ventilation. Average length of ICU stay for those patients requiring ventilatory support was 2.5 days versus 1 day for nonintubated patients.
Only 27% of patients interviewed prospectively reported use of peak flow meters in their homes as part of their self-care for asthma, and only 44% reported having ever had formal pulmonary function studies done. The pulmonary function studies done may or may not have been part of the work-up done for each reported admission.
Similarly, patient education appeared to be suboptimal, with 17% reporting having received no education in use of asthma medications or advice on when to seek professional care. Eighty percent indicated having been instructed in the proper use of metered dose inhalers, but only 35% and 17% reported education in the differences in use and effects of metered dose inhalers or oral medications, respectively. Only 16 of the 60 patients (27%) admitted for asthma reported the use of a peak flow meter at home, while 19 of the 60 patients (32%) reported having received instruction on use of a peak flow meter. Only 22% felt that they had ever received education on when to seek professional care for their asthma symptoms. All of this information was obtained from the prospective patient interviews; retrospectively examined medical records rarely documented prior asthma education.
Patient reporting of asthma-related symptoms could again only be fully appreciated when studied in a prospective manner. Eighty-two percent of patients reported that physical activity was limited during asthma exacerbations. Of greater economic concern was the 62% who reported that asthma symptoms had caused them to miss work, and 63% required a family member to miss work or school to care for them because of their asthma.
Baseline asthma severity as categorized according to EPR-2 guidelines is tabulated in Table 3 . The relative proportions of patients in each severity grouping were similar in both study groups.
Table 4 shows the adequacy of outpatient medical treatment according to EPR-2 guidelines for those asthmatics studied.
Table 5 lists the usual outpatient respiratory medications used by patients of each severity classification and includes most asthma drugs in common use. Also listed are the percentages of patients in each classification who were either not on any respiratory medication, could not remember the name of their medication, or were on a respiratory drug not considered in the EPR-2 treatment scheme, e.g., ipratropium bromide. Eighty-five percent of all patients reported using short-acting β 2 -agonists, and the percentage increased to 100% among moderate and severe persistent groups.
The 2000-mile US-Mexico border is a unique geographic and cultural region of the United States. An estimated 10.8 million people live in those areas of Texas, New Mexico, Arizona, and California adjoining the border and, while technically separated from Mexico, inhabitants of this multicultural region share similar social, environmental, economic, and health concerns. 15 Communities along the US-Mexico border tend to be poorer and less medically served than other parts of the United States. Unemployment rates in this area are three-fold higher than the national average, and approximately one-third of families live below the poverty line. 16,17 At the same time, per capita physician density is significantly lower than in many other regions of the country. 12 This study was conducted in El Paso, Texas, the largest US city located directly on the border and sharing a population of 2.2 million people with neighboring Ciudad Juarez, Chihuahua, Mexico. 18,19
The patients studied were predominantly Hispanic, female, and poor. Mexican citizenship was rarely reported, possibly from patients' concern that to do so would render them ineligible for care (although hospital policy is to provide care for all acutely ill patients). Fewer than half of the patients were employed and, of those, many reported missing work because of their asthma. A significant percentage admitted to unhealthy behaviors such as smoking, alcohol abuse, and illicit drug use. Patients appeared more likely to admit to such behaviors when questioned by the study interviewer, perhaps because of the confidentiality assured to them for research study participation. Most lacked medical insurance. Although prospective interviews provided more complete data than medical record reviews, both showed a reliance on US-based health care for asthma treatment, but often such care was provided in the urgent care setting. While most patients (64%) used a US medical provider, 31% identified an ED physician as their primary provider of medical care. None received regular medical treatment from a pulmonary or allergy specialist.
The treatment of acutely ill asthmatics accounts for a large portion of health care at the county hospital in El Paso . For the 3-year pooled period, 166 patient admissions totaled 594 hospital days, 13 patients had multiple admissions accounting for 268 hospital days, and 105 patients had single admissions accounting for 326 hospital days. Twenty-three percent of the admissions could be attributed to persons requiring multiple hospitalizations. For every acutely ill asthmatic patient admitted to Thomason Hospital during this time, 7 were treated and released from the ED (Thomas Hospital, principal adult discharge diagnoses, 2000-2005). As asthma is a chronic disease that is best managed both in terms of morbidity and cost by regular outpatient care by qualified physicians, the practice of waiting until exacerbations are so severe as to require hospitalization is both dangerous and expensive. 20
By comparing EPR-2 severity classes and corresponding treatment guidelines, our data suggest that those hospitalized asthmatics in this study were often on inadequate outpatient medical regimens. Only 46% of all patients were receiving medical therapy appropriate for their disease severity. For both retrospective and prospective groups, only 25% of the pooled mild persistent patients reported appropriate therapy, with 46% and 33% reported for the moderate persistent and severe persistent groups, respectively.
Shortcomings of usual therapy became further accentuated when the relative size of each severity group was considered. Those patients with mild intermittent asthma requiring simply as-needed β 2 -agonist medication generally met appropriate care criteria (65%) but constituted a minority of those asthmatics hospitalized (24%). Most of the hospitalized patients (69%) in the study were considered to have persistent asthma and, of these, 40% were considered to be on acceptable outpatient medicines. Only 35% of patients with more severe forms of asthma requiring more complex medical regimens were considered to be receiving adequate medical therapy.
The most apparent treatment deficiency appeared to be a lack of inhaled corticosteroid use. Although use of inhaled corticosteroid medications increased with disease severity, only 49 out of 127 (39%) of patients whose level of severity specifically dictated their use reported taking them. Furthermore, it was not possible to differentiate low-, medium-, or high-dose inhaled corticosteroid use from the data collected; thus, the percentage on appropriate-dose inhaled steroids could have been even lower. Use of daily oral corticosteroid was appropriate in severe persistent asthmatics, but a significant percentage of patients with lesser severities reported such use.
While the primary intent of this study was to assess adequacy of outpatient asthma care in terms of adherence to relatively standardized stepwise pharmacologic therapy, NAEPP guidelines delineate several additional key facets of effective asthma management worthy of comment in this group of asthmatic patients.
Among the hospitalized asthmatics studied, few had an established and well-documented diagnosis of asthma. Fewer than half of the patients had ever undergone pulmonary function testing and none received outpatient care by a pulmonologist or allergist. In fact, most patients could not identify a consistent source of medical care from which pulmonary function testing could have been obtained. Thirty-one percent of the prospectively interviewed group cited an ED physician as their usual medical care provider.
Study patients lacked practical knowledge about asthma and its treatment. Although most reported having been taught how to use a metered dose inhaler, few had been taught the effects and rationale of use of the different classes of inhaled asthma medications. Fewer patients reported instruction on the use of a peak flow meter or when to seek professional care for their asthma symptoms.
Prospective patient interviews to assess asthma severity and usual outpatient care appeared to be a superior method of data collection compared with retrospective chart reviews. Having a skilled interviewer provided much more complete information as evidenced by significantly fewer "unknown" responses. The number of annual hospital admissions for asthma appeared much higher during the prospective portion of the study when patients were identified from ED admission registries than when identified retrospectively from discharge diagnosis coding. Most ED admission asthma diagnoses were felt to be valid by investigators, and both patient groups were similar demographically and in terms of asthma severity and usual medication use. This suggests that asthma diagnosis coding at time of discharge may underreport the true number of asthmatics hospitalized at this institution.
Use of self-reported data is a limitation of this study. Patient recall of medical information was occasionally inconsistent with factual data that could be confirmed by medical and hospital pharmacy records. There was discordance between the number of times patients reported ED treatment or actual hospitalization for their asthma and the number of times such care was actually documented. Because most asthma medications can be easily obtained from Mexico, at a lower cost and without a physician's prescription, there was often no way to independently verify reported medication use. Objective pulmonary function testing data to complement the patient-reported symptom and medication use method of determining asthma severity would have been useful but were generally not available.
Patients with asthma hospitalized at the county hospital in El Paso, Texas, appear to receive suboptimal outpatient care in several respects. Their usual medical therapies often lack any long-term anti-inflammatory component, their baseline lung function is rarely measured objectively, and they lack education in asthma medications, the use of peak flow meters for self-monitoring, and when to seek treatment. These asthma management deficiencies may be exacerbated, and to a large extent explained, by the lack of chronic care of these patients by medical providers skilled in the diagnosis and management of asthma.
We thank Martha Mendoza, José C. Rodriguez, Judy Johnson, Monica Blancas, and Sylvia Dela Cruz for assistance in preparation of this manuscript.
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