National Asthma Council Australia s six step asthma management plan: is it working for young adults?

Transcription

1 National Asthma Council Australia s six step asthma management plan: is it working for young adults? National Asthma Council Australia s six step asthma management plan: is it working for young adults? Didy Button, Flinders University Asthma is a worldwide public health issue with increasing incidence and effect on mortality and morbidity across the entire life span. This paper outlines the increasing incidence of asthma in Australia compared to worldwide trends, together with strategies put forward by Global Initiatives for Asthma. Fortunately in Australia, deaths from asthma are decreasing. The lowered death rate from asthma in Australia has been attributed to management strategies formulated by the National Asthma Council Australia. One such strategy is the Six step asthma management plan. This plan is promulgated as a way to decrease mortality and morbidity for all people with asthma. Morbidity from asthma has not shown the same decrease with many people in the community continuing to experience asthma symptoms that decrease their quality of life. Of particular focus in this paper is where the six step management plan is failing young Australian adults. Firstly, health education is not targeting young adults. Secondly, the idea that young adults, when they are well, will attend their local doctor to have their asthma assessed warrants challenging. Finally, while young adults have been identified by the National Asthma Council as being an atrisk group, there are no strategies to address this group in our community who are experiencing considerable morbidity. Nurses in Australia are well placed to provide focused interventions to assist young adults manage this challenging chronic illness. Key words: asthma management, young adults, nursing Didy Button RN MNg GradDipEd(Adult), Lecturer, School of Nursing & Midwifery, Faculty of Health Sciences, Flinders University, Adelaide. didy.button@flinders.edu.au Introduction More than 300 million people around the world have asthma, and the incidence is increasing (Global Initiative for Asthma 2002). In Australia, approximately two million people suffer from asthma, the most widespread chronic health problem (National Asthma Council 2001a). When compared with other countries, Australia is included with Brazil, Canada, Ireland, New Zealand, Peru, and the United Kingdom as having the highest prevalence of asthma symptoms (International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee 1998). In a recent study, current wheeze was found in 27% of Australian children and to be increasing by 1.4% per year (Woolcock et al 2001). Wheeze in adults was lower and appeared to be stable. The prevalence of persistent asthma (wheezing episodes with abnormal airway function between episodes) in children has increased from 5% to 9% in the past 20 years, and in adults the prevalence is 5-6%. Alarmingly, the study found that up to 80% of adults with persistent asthma have abnormal lung functions. Since peaking in 1989, asthma deaths in Australia have decreased by 28%, but the mortality rate is still twice that of England (Woolcock et al 2001). Decreasing asthma mortality It is pleasing to see the death rate from asthma in Australia is declining. However, in 1998 there were still 685 deaths from asthma in Australia (National Asthma Council 1999). The declining trend has occurred across all age and sex groups. Woolcock et al (2001) claimed that improved asthma management, implemented through the National Asthma Council, best explained this trend. Despite improving mortality rates in Australia, the rate of 0.61 per 100,000 people aged 5-34 years is almost double that of England (0.35 per 100,000) (Office for National Statistics 1997). This indicates there is still room for improvement in asthma management practices. When examining the morbidity statistics, improvement in quality of life for people with asthma is not evident for young adults. Asthma morbidity in Australia In spite of improved medications, asthma is the most commonly Collegian Vol 10 No

2 recorded long-term condition in young people between the ages of 10 and 24 years (Australian Institute of Health and Welfare 2001). Current management strategies are lowering the death rate but do not appear to impact upon the long-term burden of asthma as a chronic illness in the Australian community. This continuing morbidity is also reflected in findings from a survey taken in February 2002 that found one in 10 people with asthma described their asthma as severe (National Asthma Council 2002a). One in 10 people with asthma had been admitted to hospital for emergency asthma treatment in the previous 12 months. A third of people with asthma used their reliever medication at least once a day. Half of the people with asthma only took their preventer medication when they suffered symptoms or when their asthma was out of control. Of those describing their asthma as severe, a third only took their preventer medication when they suffered symptoms or when their asthma was out of control. Of people who stated their asthma was moderate, one in five had been admitted to hospital for emergency treatment in the previous 12 months. This survey demonstrates the increasing impact of asthma on Australians. Disappointingly, it also demonstrates a continuing lack of understanding about the effective use of asthma medications by those in the survey. Organisations and strategies to manage asthma Global Initiatives for Asthma (GINA) was launched in 1993 as the result of collaboration between the National Heart, Lung and Blood Institute (NHLBI), the National Institutes of Health (NIH) of the USA, and the World Health Organization (WHO). The objective of GINA is to work with health care professionals and public officials around the world to reduce asthma prevalence, morbidity, and mortality (Global Initiative for Asthma 2002). In 1990 in Australia, respiratory physicians from the Thoracic Society of Australia and New Zealand formed the National Asthma Campaign, the name of which was changed in July 2001 to National Asthma Council Australia. The aim was to bring together all forms of undertakings in the field of asthma in order to improve the quality of life and health outcomes of people with asthma and their carers. The management plan is a strategy to provide enhanced communication between health professionals and people with asthma - decreasing the prevalence of asthma in the Australian community and resulting in reduced social and economic impact of the disease to the community. The Australian Health Ministers Conference in 1999 acknowledged the importance of asthma as a health issue by making it a National Health Priority Area. Following this, $48.4 million were allocated to enable general practitioners to improve care for people with moderate to severe asthma (National Asthma Council 2002b). In the same year, the Cooperative Research Centre for Asthma (CRCA) was established. CRCA is a joint venture between: two medical research institutes (Institute of Respiratory Medicine and Garvan Institute of Medical Research); three universities (University of Sydney, Monash University, and University of Western Australia); six pharmaceutical companies; and the New South Wales Department of Health (Woolcock et al 2001). The mission of CRCA is to reduce the burden of asthma on the Australian community. CRCA has three research programmes: the prevention of asthma; treatment of asthma; and diagnostic, delivery and monitoring devices involved with asthma management. Current asthma management National Asthma Council Australia published the first Asthma management handbook in 1993 (with the fifth edition now available online at The handbook was designed to assist health professionals to provide the highest quality of care for people with asthma with the hope of reducing the rising death rate attributed to the condition. One of the essential strategies of the handbook is a six step asthma management plan (see Table 1). The plan was created to provide a consistent framework to guide all health professionals working with people who have asthma and their families. Summary of the six step asthma management plan First step: assess the severity of the person s asthma. Asthma is a chronic condition and so it is optimal to assess the person when they are not having an acute exacerbation of their asthma Table 1: Summary of the National Asthma Council six step asthma management plan (adapted from National Asthma Council 2002b) 1 Assess asthma severity Assess overall severity when the person is stable,not during an acute episode. 2 Achieve best lung function Treat with intensive asthma therapy until best lung function is achieved. Back titrate to lowest dose that maintains good symptom control and best lung function. 3 Maintain best lung function Identify and avoid trigger factors and inappropriate medication. avoid trigger factors 4 Maintain best lung function Treat with the least number of medications and with optimal medication use the minimum doses necessary. Ensure the person understands the difference between preventer, reliever and symptom controller medications. 5 Develop an action plan Discuss and write an individualised plan for the management of exacerbations. Detail the increases in medication doses and include when and how to gain rapid access to medical care. 6 Educate and review regularly Ensure the person and their family understand the disease, the rationale for their treatment and how to implement their Action Plan. Emphasise the need for regular review, even when asthma is well controlled. Review inhaler technique at each consultation. Review adherence at each consultation. 38 Collegian Vol 10 No

3 National Asthma Council Australia s six step asthma management plan: is it working for young adults? Table 2: Symptoms and indicators of asthma (adapted from National Asthma Council 2002b) Symptoms/Indicators Mild Moderate Severe Wheeze, tightness cough, dyspnoea Occasional eg with viral Most days Every day infection or exercise Nocturnal symptoms Absent < Once/week > Once/week Asthma symptoms on wakening Absent < Once/week > Once/week Hospital admission or emergency department Absent Usually not Usually attendance in past year (for adults) Previous life-threatening Absent Usually not May have a history Attack (ICU or ventilator) Bronchodilator use < Twice/week Most days > 3-4 day FEV 1 (% predicted) > 80% 60-80% < 60% Morning peak flow on waking > 90% recent best 80-90% best < 80% best (Jenkins 2000). Asthma in adults is categorised as either mild, moderate or severe (see Table 2). Assessment of asthma when it is not acute is problematic, because then most people forget about having asthma and do not attend their general practitioner for assessment (Vamos 2000). Second step: achieve best lung function by intensive asthma medication until maximal reversal of airway inflammation and obstruction is obtained. Once achieved, medication is titrated back to the lowest dose to maintain symptom control and best lung function. Third step: identification of triggers that exacerbate asthma symptoms and accessing appropriate medication. Once triggers have been identified and best lung function achieved with minimum medication, the fourth step can be implemented. Fourth step: maintain the level of control reached in step three. This is achieved by ensuring the person with asthma has a sound understanding about reliever and preventer medications and strategies are in place to minimise adverse effects from medications. Fifth step: develop an action plan. This is a written individualised plan for the management of exacerbations, including when increases in medication doses are required and rapid access to medical care is indicated. Sixth step: review and educate the person and their family about the disease, the rationale for treatment with different medications, and how and when to implement their personal action plan (National Asthma Council 2002b). An evidence based review of the six step asthma management plan conducted in 1999 supported the use of inhaled corticosteroids to achieve best lung function (step two of the plan) (Coughlan et al 1999). Allergen immunotherapy was effective as a strategy in certain people with asthma who were atopic in line with step three of the plan. Coughlan et al (1999) also found that maintaining best lung function was often achieved by using more than one type of asthma medication with each person. Family therapy as an adjunct to medication was also shown to be effective in maintaining best lung function. The fifth step of developing an action plan was supported by the review as effective. Evidence in support of the sixth step of the plan included the provision of information alone or coupled with an emergency admission. Information coupled with self-management, regular review, and a written action plan was effective. The review also found self-managed asthma and doctor-managed asthma was equally effective. Coughlan et al s (1999) review is now five years old; whilst it did confirm positive aspects of current asthma management in Australia, the continuing level of morbidity of young adults (Reid et al 2000) requires formal review. Health education is not targeting young adults Shah et al (1998) showed targeted asthma education provided for high school students through the Triple A (adolescent asthma action) program promoted self-management behaviours for asthma in adolescents. Further evaluation of the program found clinically relevant improvement in quality of life and related morbidity in students with asthma (Gibson et al 1998, Shah et al 2001). Wider dissemination of this program in schools could play an important part in reducing the burden of asthma in adolescents and young adults, but the National Asthma Council currently has no strategies to increase young people s knowledge about changes in their asthma. Apart from the video Get A Life, focusing on emergency management of asthma in teenagers, there are no resources targeting young adults that explain the changing clinical features from childhood asthma to adult asthma, and the management required. Young adults with asthma in Australia Young adults may unconsciously be taking risks with their asthma because they are not aware of changes in the presentation of their asthma now that their lungs are fully developed. A review of the literature surrounding risk taking behaviour in young people between 15 and 24 years found risk taking is endemic, universal, inescapable, not always conscious, and sometimes is desirable (Hewitt et al 1995). Examples of risk taking for the person with asthma include not taking their reliever medication before being exposed to a known trigger such as exercise and cigarette smoke, or choosing not to take their reliever medication with them when they go out, relying on borrowing a friend s medication should the need arise (Glover et al 1996). Potentially harmful risk taking is widespread in this age group. In the age group, risk taking focuses on the gains rather than the losses of engaging in risk behaviour. It is not due to more optimism bias in this age group, as optimism bias increases with age (Hewitt et al 1995). Collegian Vol 10 No

4 Unfortunately, young adults who have experienced asthma since childhood are at particular risk because asthma in adults is different from asthma as a child. Unlike asthma in childhood, young adults will no longer have episodes of exacerbation of asthma interspersed with sometimes long asymptomatic periods when their lungs will recover fully (Jenkins 2000). As young adults, their lungs are more likely to sustain a level of inflammation, which amplifies bronchial hyper-responsiveness and increases the likelihood of more frequent acute asthma episodes. Yet the use of inhaled corticosteroids in young adults is low (Reid et al 2000). Young adults are relying on past childhood experiences with different manifestations of asthma and consequently are exposing themselves to the risk of acute exacerbations. These young adults have to renegotiate priorities with a new form of asthma experienced in their adult bodies. It has been suggested by Jenkins (2000) that this lack of familiarity with the clinical features of adult asthma may account for the delay in seeking medical intervention until the person s asthma is moderately severe with minimally reversible airway obstruction. Young adults with chronic disease are also at a high risk of developing life-threatening asthma. A study by Reid et al (2000) found over one quarter of all subjects in a cohort of 1,642 individuals aged between 20 and 44 years with asthma required care in an emergency department at some time. In addition, 14% reported the need for admission overnight on at least one occasion. The majority of these young adults with asthma from Victoria reported symptoms during the previous year, but despite this most had not had a recent medical review and few had ever seen a respiratory specialist. The over-reliance on beta 2 -agonists (reliever medication that dilates the bronchioles), in combination with under-use of inhaled corticosteroids also persists. Reid et al (2000) argued convincingly that this probably contributes to Australia s continuing high asthma morbidity and mortality rates. The study concluded that the majority of young Melbourne adults with asthma appear to have dis-ease, which is sub-optimally controlled and poorly understood. Understanding how young people construe risky situations is paramount to making progress in harm minimisation with asthma. A holistic examination of young people, and the environment in which they live, is needed - including the media, legislation, and social and cultural norms on youthfulness. In order to reinforce safe behaviours across the board, these social norms need to be questioned, thereby allowing the promotion of health-enhancing behaviours implicitly and explicitly to young people. Learning and habit formation plays a significant role in the development and sustainment of risky behaviours (Hewitt et al 1995). Examples of this type of reinforcement include advertisements on television, which depict young adults driving the latest model cars at great speeds with little regard for the road rules. Another example is clubs that offer free admission to young women with lower price drinks, to entice young men to the club who may hope to find a good time with the intoxicated young women. Assessment of asthma severity in young adults is problematic Lubkin and Larsen (2002) argued the Western health care system was never designed for prevention and maintenance of chronic health conditions, but rather for identifying diseases, treating symptoms, and producing cures. It is a health care system designed to provide acute and episodic care, and it generally achieves this type of care effectively. However, when considering people with chronic health conditions, this model of health care does not fit their needs and a mismatch occurs between what is needed for care and what is offered as care. Young adults with asthma are one such group who have a chronic illness and whose needs are not being met. Unlike childhood asthma symptoms, which are marked by episodes of acute exacerbations followed by periods of no symptoms when lung function returns to normal (Bronnimann & Burrows 1986), the symptoms for adults consist of dyspnoea and chest tightness without the wheeze from childhood. Thus it was contended by Jenkins (2000) that adults may fail to recognise or perceive increasing limitation due to airway narrowing as an indication of worsening asthma because of its unfamiliar insidious onset. It has been suggested by Jenkins (2000) that this explains why adults generally present late with moderately severe asthma that does not respond well to bronchodilator medication due to longstanding airway inflammation. Young adults and the six step asthma management plan In 2001, asthma was the most commonly recorded long-term condition in young people between the ages of 10 and 24 years in Australia (Australian Institute of Health and Welfare 2001). While health professionals see the young adult as having a chronic illness, the perception of young adults is quite different. Most do not see themselves as chronically ill, instead they get asthma, which comes and goes and generally is a nuisance. Many young adults with asthma do not seek any interventions until they are very unwell with their asthma and on many occasions access emergency department services (Campbell & Ruffin 2000). One reason for this could be their lack of understanding about the adult presentation of asthma (Jenkins 2000). Smoking of tobacco is common among young adults aged years with 24% actively smoking (Australian Bureau of Statistics 2000). Alarmingly, according to the 1998 National Household Drug Survey, more than half (53%) of those aged years had smoked (Australian Institute of Health and Welfare 1999). Tobacco smoking, as well as related drug abuse and passive exposure to tobacco, is seen as a major obstacle to managing asthma in young adults (Randolph & Fraser 1999). The most current data from the National Asthma Council regarding costs either being expended or being lost from productivity because of asthma, was estimated at being between $585 to $720 million. 40 Collegian Vol 10 No

5 National Asthma Council Australia s six step asthma management plan: is it working for young adults? The total cost consists of around $320 million in medical related costs and around $260 to $400 million in indirect costs from lost productivity (National Asthma Campaign 1992). The Living with Asthma Study (Merck, Sharpe & Dohme 1999) found asthma also had a substantial impact upon child and adult lifestyles. Both child and adult groups felt tired and frustrated because of their asthma. One in five children did not ride a bike or play at school or with animals, and one in three did not participate in organised sport. One in four adults avoided socialising in restaurants, pubs, and clubs because of the smoky environment. Abramson et al (1996) assessed management practices and treatment perceptions among young adults with asthma in Melbourne as part of the European Community Respiratory Health Survey (ECRHS) in A number of characteristic behaviours found in people who had died from their asthma or had experienced near-fatal asthma were also present in young adults. For example, less than 11% used their inhaled corticosteroids medication on a daily basis; however, 37% had used inhaled corticosteroids in the preceding year. Even during exacerbations, adherence only rose to 54% - meaning that although the young adults were ill with asthma, nearly half chose not to take their inhaled corticosteroid medication. When considering the use of reliever medication used for breathlessness, only 52% took their reliever at the start of the attack with the remaining 48% waiting until symptoms became severe. Over one quarter of all young adults in the study reported needing care in an emergency department at some time and 14% reported the need for admission overnight on at least one occasion. The researchers found the majority of these young adults with asthma reported symptoms during the previous year, but despite this, most had not had a recent medical review and few had ever seen a respiratory specialist (Abramson et al 1996). Over-reliance on beta 2 -agonists, in combination with underuse of inhaled corticosteroids, probably contributes to Australia s continuing high asthma morbidity and mortality rates. The interest in young adults as a group who are over represented in the asthma morbidity data is increasingly evident in quantitative studies. Yet little is known about the young adults of today and how they are negotiating their lives with this chronic illness that impacts on many aspects of their work, leisure, and social lives. Young adults are required to make conscious and unconscious choices about dealing with the everyday world and how best to negotiate their way through adulthood with these unpredictable bodies. There is a need for research from the interpretive paradigm to contribute new understandings about what the issues are for young adults who have this chronic illness known as asthma. Nurses are well positioned to improve health outcomes for young adults Nurses are the largest population of health professionals, with 1,856,000 registered and enrolled nurses working in the Australian health care system. This represents over 56% of the health professional workforce (Australian Bureau of Statistics 2002). Registered nurses working in both community and acute settings, visiting people in their homes or at their work, and caring for them in hospital, are well positioned to provide specific brief interventions for people with asthma. Currently, however, only a few assigned the title of respiratory nurse or asthma educator are providing this essential service with most of them situated in tertiary health centres. Asthma management should become as common for nurses as diabetes management. Allowing young adults to discuss what it is like to live with asthma provides nurses and other health professionals with an opportunity to understand young adults experiences with asthma in contemporary Australia. Stronger, focused health alliance relationships with young adults could decrease the level of morbidity many are experiencing currently with their asthma, leading to improved long-term outcomes and quality of life for young adults with asthma. Conclusion Asthma is a worldwide public health issue with increasing incidence and effect on mortality and morbidity across the entire life span. Morbidity from asthma has not shown the same decrease with many people in the community continuing to experience asthma symptoms that decrease their quality of life. In Australia, deaths from asthma peaked at 964 in 1989 (National Asthma Council 1999) and decreased to 424 in 2000 (National Asthma Council 2001b). The lowered death rate from asthma in Australia has been attributed to management strategies formulated by the National Asthma Council Australia. One such strategy is the six step asthma management plan. This plan is promulgated as a way to decrease mortality and morbidity for all people with asthma. This paper has focused on where the six step management plan is failing young Australian adults. Firstly, health education is not targeting young adults. Secondly, the idea that young adults will attend their local doctor when they are well to have their asthma assessed warrants challenging. Finally, while young adults have been identified by the National Asthma Council as being an at-risk group, there are no strategies to address this growing group in our community who are experiencing considerable morbidity. Nurses in Australia, who represent over 56% of the health professional workforce, are well placed to provided focused interventions to assist young adults to manage this challenging chronic illness. References Abramson M, Kutin J J, Raven J 1996 Risk factors for asthma among young adults in Melbourne. Respirology 1: Australian Bureau of Statistics 2000 Australia now, Australian social trends 2000 health - risk factors: trends in smoking. Australian Bureau of Statistics, Canberra Australian Bureau of Statistics 2002 Yearbook Australia Health: health workforce. Australian Bureau of Statistics, Canberra. Available online at: 86DB?Open Collegian Vol 10 No

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