A/1 Management of Asthma in the United States: Where Do We Stand? MODULE A Advanced Studies in Medicine 1
A/2 Objectives To examine the state of care of asthma in the United States with reference to National Heart, Lung, and Blood Institute (NHLBI) guidelines To understand areas of deficiency in asthma care so that health care providers are better equipped to improve it One of the most common respiratory diseases, asthma has been extensively studied. With increases in knowledge about the pathophysiology of asthma, therapeutic options for the disease have advanced significantly over the past decade, and effective control of asthma is an achievable goal for most patients. Recent data suggest that despite the advances in knowledge about asthma and the availability of effective therapy, many patients continue to suffer with poorly controlled asthma that impairs their functional ability and quality of life. Furthermore, asthma continues to exact a large financial toll on society and the health care system. This slide set examines these data regarding the state of care of asthma in the United States. By understanding the areas of deficiency in asthma care, health care providers can be better equipped to improve it. Advanced Studies in Medicine 11
A/3 NHLBI Guidelines: The Best Practice Standard Prevent chronic and troublesome symptoms Maintain (nearly) normal pulmonary function Provide optimal pharmacotherapy Maintain normal activity levels Prevent recurrent exacerbations and minimize the need for emergency department visits or hospitalizations Meet patients and families expectations of and satisfaction with asthma care National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH publication no. 97-51. In an effort to ensure that health care providers are applying new knowledge about asthma and making the best use of asthma therapy, the National Heart, Lung, and Blood Institute (NHLBI) in 1991 established guidelines for the diagnosis and management of asthma. 1 These guidelines were updated in 1997 to accommodate new information about asthma pathophysiology and means of optimizing asthma therapy. 2 The guidelines established several goals of asthma care and outlined practical means of achieving these goals. The goals of asthma care include: Maintenance of (nearly) normal pulmonary function; Prevention of chronic and troublesome symptoms; Provision of optimal pharmacotherapy with minimal or no adverse effects; Maintenance of normal activity levels; Prevention of recurrent exacerbations and minimization of the need for emergency department visits or hospitalizations; and Fulfillment of patients and families expectations of asthma care. This presentation uses the NHLBI goals as a reference to examine the state of care of asthma in the United States today. References 1. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1991. NIH Publication no. 91-3642. 2. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH Publication no. 97-51. Advanced Studies in Medicine 12
A/4 NHLBI Goal: Maintain Near-Normal Lung Function and Prevent Symptoms 1 % Patients Meeting National Institutes of Health Criteria for Intermittent Versus Persistent Asthma 8 22 19 19 2 Mild intermittent Mild persistent Moderate persistent Severe persistent Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. National Heart, Lung, and Blood Institute (NHLBI) goals of asthma care include the maintenance of near-normal lung function and the prevention of symptoms. The fact that 38% of patients in the Asthma in America survey* met National Institutes of Health criteria for moderate persistent asthma (19%) or severe persistent asthma (19%) suggests that these goals are not being met. The symptom criteria for moderate persistent asthma are (1) daily symptoms; (2) daily use of a short-acting bronchodilator; (3) exacerbations affecting activity; and (4) exacerbations occurring at least twice weekly. The symptom criteria for severe persistent asthma are (1) continual symptoms; (2) limited physical activity; and (3) frequent exacerbations. *The 1998 Asthma in America survey was conducted to obtain a comprehensive assessment of the state of asthma care in the United States. The Asthma in America survey interviewed nationally representative samples of health care providers (512 physicians, 11 nurses, 113 pharmacists) as well as current asthma patients (n = 259 including 721 parents of children with asthma). Furthermore, the Asthma in America survey included a comparison group of nonasthmatic individuals from the general adult population (n = 1). Reference Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Advanced Studies in Medicine 13
A/5 NHLBI Goal: Provide Optimal Pharmacotherapy NHLBI recommends dual-controller therapy composed of an inhaled corticosteroid and a bronchodilator as the most effective therapy for patients with moderate persistent or severe persistent asthma Fewer than half of patients with moderate persistent or severe persistent asthma used dual-controller therapy in 1999 or 2 National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH publication no. 97-51. O Connor RD, O Donnell JC. Clinical and Economic Benefits of Dual-Controller Therapy: An Evidence-Based Approach. The GlaxoSmithKline Group of Companies, USA; 21. Although the National Institutes of Health recommends dual-controller therapy comprised of an inhaled corticosteroid and a bronchodilator as the most effective therapy for patients with moderate persistent or severe persistent asthma, 1 fewer than half of patients with moderate persistent or severe persistent asthma used dual-controller therapy in 1999 or 2. 2 Thus, another of the NHLBI goals that of providing optimal pharmacotherapy with minimal or no adverse events is not being met. References 1. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH Publication no. 97-51. 2. O Connor RD, O Donnell JC. Clinical and Economic Benefits of Dual-Controller Therapy: An Evidence-Based Approach. The GlaxoSmithKline Group of Companies, USA; 21. Advanced Studies in Medicine 14
A/6 NHLBI Goal: Maintain Normal Activity Levels 1 % respondents with activity restriction 8 2 48 Sports or recreation % Patients Reporting Activity Restriction 36 36 Normal physical exertion 31 31 25 Sleep Lifestyle Housekeeping Social activities 24 Choice of job or career Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. The NHLBI guidelines establish maintenance of normal activity levels as another goal of asthma care. 1 The Asthma in America data show that many patients are prevented from performing normal activities because of their asthma. Asthma caused 25% of adults to miss work and 49% of children to miss school during the year prior to the survey. 2 In addition to work or school, recreational activities and home life were also disrupted by asthma: 48% of asthma sufferers reported limitation in sports/recreational activities. 31% reported limitation in ability to perform household chores. 31% reported that their overall lifestyle was disrupted because of asthma. 25% reported limitation of social activities. Besides impacting patients functional abilities, asthma also affected patients self-perceptions. Approximately half of patients (45%) felt that because of asthma they did not function at their full potential; 47% of adults and 34% of children reported that their expectations of their physical abilities were reduced because of asthma. A sobering one in four adults (24%) indicated that asthma had influenced their choice of job and career. References 1. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH Publication no. 97-51. 2. Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Advanced Studies in Medicine 15
A/7 NHLBI Goal: Prevent Recurrent Exacerbations and Minimize Need for Emergency Room Visits 1 % Patients Using Health Care Services % respondents using health care service in past year 8 2 9 Hospitalized 23 Emergency room visit 41 Urgent care visit 29 Unscheduled visit Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. A primary goal of asthma therapy is to prevent recurrent exacerbations of asthma and minimize the need for emergency room visits and hospitalizations. 1 The data from the Asthma in America survey, which show a relatively high rate of emergency room and urgent care visits because of asthma, suggest that this goal is not being met. 2 During the year prior to the survey, approximately: 1 in 1 patients with asthma were hospitalized because of asthma; 1 in 4 patients visited a hospital emergency room because of asthma; 1 in 5 patients required an urgent care visit because of asthma; and 1 in 3 patients had an unscheduled emergency visit to a health care provider because of asthma. Health care use was consistently higher among children with asthma compared with adults for each of these categories of care. References 1. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH Publication no. 97-51. 2. Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Advanced Studies in Medicine 16
A/8 NHLBI Goal: Meet Patients Expectations Only a Little 7% Not at All 3% Not Sure 2% The majority of patients indicates that their health care provider s advice helps them a lot in managing their asthma symptoms. Some 26% A Lot 62% Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Ironically, although the data suggest that none of the NHLBI goals for control of symptoms and maintenance of normal daily function is being adequately met for many patients, patients are generally not dissatisfied with the care they receive. 1 Sixty-two percent (62%) of patients indicated that their health care providers advice has helped a lot in managing their asthma symptoms. Nine of 1 patients in the Asthma in America study indicated that they are satisfied with their health care providers knowledge of asthma and asthma management, their health care providers abilities to explain asthma management, and their health care providers willingness to spend time with them. The NHLBI goal of meeting patients expectations of asthma care and ensuring patient satisfaction 2 is thus being met for many patients. References 1. Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. 2. National Asthma Education and Prevention Program. Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Dept of Health and Human Services, National Institutes of Health; 1997. NIH Publication no. 97-51. Advanced Studies in Medicine 17
A/9 Patient Ratings of Asthma Control % Patients Rating Their Asthma as Controlled Versus Poorly Controlled Patients with moderate persistent asthma Patients with severe persistent asthma 1 1 % respondents 8 2 36 4 8 2 32 52 16 Completely or well controlled Somewhat controlled Poorly controlled or uncontrolled Completely or well controlled Somewhat controlled Poorly controlled or uncontrolled Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. However, other data from the Asthma in America survey suggest that, satisfaction with their asthma care notwithstanding, patients are poor judges of the severity of their asthma and degree of control over it. Of patients with moderate persistent asthma (ie, meeting symptom criteria of daily symptoms, daily use of a short-acting bronchodilator, exacerbations affecting activity, and exacerbations at least twice weekly), % considered their asthma to be well controlled or completely controlled. Of patients with severe persistent asthma (ie, meeting symptom criteria of continual symptoms, limited physical activity, and frequent exacerbations), 32% considered their asthma to be well controlled or completely controlled. Moreover, 37% of patients with severe persistent asthma and 57% of patients with moderate persistent asthma considered themselves to have mild or no symptoms. Besides reflecting a high frequency of poor lung function and symptom control among many patients with asthma, these data show that patients underestimate the severity of their disease and overestimate their control over their asthma. Reference Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Advanced Studies in Medicine 18
A/1 Patients and Health Care Providers on Asthma Care Practices % Patients or Health Care Providers Indicating That Specific Asthma Care Practices Are Being Implemented 1 Patient Health Care Provider 92 % respondents 8 27 7 35 7 55 2 Developed written action plan Given lungfunction test Scheduled Follow-up visits Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Results of the Asthma in America survey show that although patients are generally satisfied with their asthma care, many patients report that they are receiving a standard of care lower than that recommended by NHLBI guidelines. Furthermore, the data reveal that patients and health care providers differ in their perceptions about the degree to which the NHLBI components of asthma care are being implemented. For example, 7% of health care providers indicated that they had developed written action plans for asthma management with their patients and that they regularly perform pulmonary function tests. In contrast, only 35% of patients indicated that their health care providers perform pulmonary function tests, and 27% of patients indicated that their health care providers had worked with them to develop written action plans. Reference Asthma in America: Asthma Statistics. Available at: www.asthmainamerica.com/statistics.htm. Accessed July 18, 21. Advanced Studies in Medicine 19
A/11 Conclusions Asthma care is falling short of the NHLBI goals. Poor asthma control impairs functional ability and quality of life for many patients. Approximately half of those with moderate persistent or severe persistent asthma are not receiving appropriate pharmacotherapy. Despite these problems, patients do not report dissatisfaction with care. Patients overestimate their degree of control over asthma. Health care providers compared with patients overestimate the degree to which common asthma care practices are being followed. These results underscore patients and health care providers need for additional education. Considered together, these data demonstrate that asthma care is falling short of the goals established by the NHLBI. Poor control of symptoms and lung function significantly impairs functional ability and quality of life in a substantial proportion of patients with asthma, and approximately half of those with moderate persistent or severe persistent asthma are not receiving appropriate therapy. As a result, asthma exacerbations, which are often managed via emergency and urgent care services, exact a large toll in financial and human resources. Despite these problems, patients do not report dissatisfaction with asthma care. Furthermore, while patients report significant asthma-related disability and are acutely aware of the impact of asthma on their daily functioning, they overestimate the degree of control they have over their symptoms. These findings underscore the need for additional patient education on the significance of asthma symptoms, the characteristics of well-controlled asthma, and the high level of functioning that is possible with currently available therapy. The results suggest that increased education of health care providers is also necessary. Health care providers relative to patients overestimate the degree to which common asthma care practices are being followed, and many do not prescribe pharmacotherapies appropriate for the severity of symptoms that their patients report. Health care providers should examine their behavior to ensure that they are practicing the best asthma-control techniques and judiciously prescribing pharmacotherapy. With the level of asthma control possible through currently available interventions, the NHLBI goals of asthma care are achievable. Advanced Studies in Medicine 2