| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Dr. Poponick is Senior Instructor at Case Western Reserve University.
Correspondence to: Janet Poponick, MD, MetroHealth Medical Center, Department of Emergency Medicine, 2500 MetroHealth Dr, Cleveland, OH 44109; jpoponick@metrohealth.org
Asthma is a very common chronic disease with a self-reported prevalence of 13.7 million persons (1993–94 survey).1 In 1995, there were an estimated 1.8 million emergency department visits for treatment of acute asthma.1 Office visits for asthma have more than doubled in the past 20 years.1 Estimated costs of asthma management exceed $5 billion per year, with half of all costs used for acute exacerbations that are managed in the hospital setting.2 3 With this type of expenditure for asthma, why are so many of our patients not doing well?
To improve the overall management of asthma, the National Asthma Education Program expert panel published guidelines in 1991,4 and an international consensus was published in 1992.5 The statements stress the importance of asthma education, self-monitoring of asthma symptoms, and outlines a stepwise approach to asthma care including the use of inhaled corticosteroids for moderate and severe asthma. They also recommend providing the patient with a written "plan of action" that can be initiated at the onset of an acute attack. In discussions with colleagues and teaching of residents, we all refer to the consensus statement. But why has this not become actual practice?
There are many reasons that can be listed: psychosocial issues including the inability to afford medications, the lack of a primary care physician, and continued exposure to known irritants, especially cigarette smoking. In this issue of CHEST (see page 1638), McD Taylor et al surveyed their asthma population in a Pittsburgh emergency department and compared the patient’s knowledge and their outpatient treatment with the consensus guidelines. Patients in this study and those using hospital emergency departments generally have a poor understanding of their disease and poor management techniques.
Acccording to McD Taylor et al, approximately 60% of patients were undertreated with medications, and > 80% had no plan of action for acute exacerbations. Their patient population had a poor understanding of their disease and were unclear on the use of their medications. With regards to the recommendation of inhaled steroids for moderate to severe disease, only 50% of their patient population used some form of steroid therapy (but again, some did not understand its proper use).
Another recent study by Legorreta et al6 demonstrated dismal results also. Of interest, this study was conducted by written survey of an asthma population enrolled in a large health maintenance organization (HMO) in California. Of those patients with severe asthma, 72% had a steroid inhaler, but only 54% of those patients used it daily. As for monitoring peak flow, only 26% of respondents had a peak flowmeter, but only 16% of those patients used it daily to monitor their disease. Remember, this was a population of patients with insurance who should have been able to obtain medication, peak flowmeters, and access to care.
Many patients seeking care in emergency departments may not have a primary care provider. According to McD Taylor et al, only 38% of the patients could name a primary physician as the person from whom they obtained asthma education. Therefore, a significant number of patients received information from other sources. Many did not see a physician on a regular basis, which is important for patient education and adjustment of medications. Perhaps if the patient had a primary care physician with regularly scheduled follow-up visits, they would be managed and educated more appropriately and not use the emergency department for care.
The article by Kolbe et al7 should remind us that other factors influence the ability of our patients to manage their disease. Asthma knowledge was compared to actual behavior during an acute attack. It was found that a reasonable knowledge base alone does not translate into appropriate action. Factors that may influence the "gap" include non-European descent, feeling stigmatized by the disease, high anxiety, concerns over the cost of medical care, living on Social Security benefits alone, low education, and the recent loss of a partner. When seeing asthma patients, it is important to realize that there are other social and psychological issues influencing that particular individual. Asthma education should begin with dealing with some of these issues that affect the everyday life of our patients.
Education is a big principle of current asthma management. The patient should understand their disease process, understand their medication and how to use it, and be able to react to changes in their disease by symptoms and/or actual measured peak flow. In the above-mentioned studies, it is clearly demonstrated that these points are not being made to our patients. Peak flowmeters were not widely available or used by this patient population. Peak flow is a valuable tool to aide the patient and physician in the management of asthma. It provides an objective measurement of airflow obstruction. However, it is only valuable when used, and those who use the peak flowmeters are usually well-monitored, well-motivated patients.8 Peak flow-based action plans have been shown to improve asthma control and reduce the number of emergency department visits.9 However, this has been a short-term effect. The patients may benefit from continued support and reminders from their primary care provider or asthma specialist concerning peak flow measurement and the use of inhalers. Education and good follow-up with a provider seems to influence the use of an inhaled steroid, at least over a short-term period.9
The guidelines suggest that all asthmatic patients measure their peak flow and symptoms daily. Some patients can only follow their symptoms, and those patients should be educated to do so. While it would be beneficial to the patient to have a peak flowmeter and to use it daily, the reality is that only well-motivated patients will do so. Certainly knowing the patient’s best peak flow is a valuable tool to guide emergency management. Perhaps measuring the peak flow in the office when the patient is feeling well is the best we can do for some patients!
The article by McD Taylor et al, along with the study by Legorreta et al6 should be a wake-up call for all who see asthma patients, whether it is in the primary care setting, the asthma specialty setting, or in the emergency department. All of us need to work harder at educating our patients and helping them deal with all aspects of their disease. Yes, the medications can be expensive, but this seems to be an excuse. The study by Legorreta et al6 was conducted with people enrolled at an HMO; all patients should have had their medicines provided through their health plans. There are programs available to patients who cannot afford medication such as state insurance plans, or even through some of the pharmaceutical companies.
We may not be able to motivate our patients to do everything suggested in the guidelines, but we can strive for a few of the basics. All of us, including those practicing in the emergency department setting, can make an effort to do better. At each patient encounter, we can readdress the basic issues and educate our patients about their disease. The most important aspect of education is inhaler technique and a review of the medications. Inhaler technique is generally suboptimal, and many may benefit from the addition of a spacer. Explain the need for daily use of an inhaled steroid, and explain the use of a "quick reliever" medicine. Give them a specific plan of action when they leave the emergency department or urgent-care clinic. This plan can be symptom or peak-flow based and should be adequate until they see their primary care provider in a few days. Stress the importance of follow-up in 2 to 3 days. Finally, stress the importance of avoiding known irritants, especially cigarettes. If we as physicians do basic education at every visit, we will eventually do better!
References
Read all eLetters
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
