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(Chest. 1999;116:1638-1645.)
© 1999 American College of Chest Physicians

Current Outpatient Management of Asthma Shows Poor Compliance With International Consensus Guidelines*

David McD Taylor, MD; Thomas E. Auble, PhD; William J. Calhoun, MD, FCCP and Vincent N. Mosesso, Jr., MD

* From the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Correspondence to: Vincent N. Mosesso Jr., MD, 230 McKee Place, Suite 400, Pittsburgh, PA 15213; e-mail: vnm{at}med.pitt.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: This study aimed to establish whether the outpatient management of patients presenting with an asthma exacerbation to the emergency department (ED) was in compliance with the 1992 guidelines of the "International Consensus Report on the Diagnosis and Management of Asthma."

Design: Prospective, observational study using a researcher-administered questionnaire.

Setting: University tertiary referral ED.

Patients: Convenience sample of asthmatics (aged 18 to 54 years) presenting for asthma treatment between July 1, 1997, and June 30, 1998.

Results: Eighty-five asthmatic patients were enrolled. Of these, 34 patients (40%) smoked, 53 patients (62%) were undertreated with medication when compared to the consensus guidelines, and 74 patients (87%) had no written "plan of action." During an asthma attack, 9 patients (11%) did not use a bronchodilator as first-line action and 76 patients (89%) did not commence or increase the use of an inhaled steroid. Forty-nine patients (58%) did not know that bronchospasm occurred in asthma, and 53 patients (62%) did not know that bronchial swelling occurred. Twenty-six patients (31%) thought short-acting bronchodilator drugs were asthma preventers. Sixty-two patients (73%) could not adequately define peak expiratory flow (PF), 41 patients (48%) did not own a PF meter, and only 8 patients (9%) determined their PF daily. Fifty-three patients (62%) were reviewed by a physician once a year or less, and 18 patients (21%) noted family and friends as their only source of asthma education.

Conclusions: The outpatient management of most asthma patients presenting to the ED did not comply with the consensus guidelines, and asthma knowledge was poor.

Key Words: asthma • emergency department • guidelines • management


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Asthma affects 4 to 5% of the population of the United States,1 and its prevalence is increasing.1 2 3 4 5 Although pharmaceutic and clinical research is likely to develop new drugs and therapies for the secondary prevention of asthma, it is incumbent on clinicians to ensure that current knowledge and treatments are utilized to their maximum effect. The major factors contributing to asthma morbidity and mortality are underdiagnosis and undertreatment,2 6 7 and most exacerbations can be prevented if management is comprehensive and ongoing.2 7

Many countries have published asthma management guidelines that aim to standardize and improve asthma management.2 6 7 8 9 There is evidence that the implementation of such guidelines leads to an increased awareness and improved management of patients.8 10 The "International Consensus Report on the Diagnosis and Management of Asthma" (the Consensus) was published in 1992 to provide a coordinated, international approach to asthma management best practice.2

The Consensus describes six interrelated parts to asthma management.2 Part 1 recommends that all patients be educated to develop a partnership in asthma management. Patients should have a knowledge of asthma pathophysiology; the role of chronic irritants and allergens; and the actions, dose regimens, and side effects of their drugs. They should have good drug inhaler and peak expiratory flow (PF) technique and instructions for managing deteriorating asthma control. Part 2 recommends that patients assess and monitor asthma severity with objective measures of lung function. The frequent use of PF meters allows patients to know their baseline and best PF, their diurnal variation, and to detect an objective deterioration in lung function.2 6 8 Part 3 recommends that patients have a good knowledge of asthma triggers, an understanding of how to avoid and control them, and the motivation to do so. Part 4 recommends that medication plans for chronic asthma management be established. Patients should have a medication regimen tailored to their severity classification, a step-wise approach to drug therapy, and a system for asthma management.2 6 7 8 Part 5 recommends that plans for managing exacerbations be established.

Patients should have a written "plan of action" for the home management of asthma, which includes advice on PF monitoring, drug adjustment, and crisis management. Part 6 recommends that regular follow-up care be provided. Patients should have a physician review of asthma management every 1 to 6 months, with referral to an asthma specialist for all severe asthmatics and those patients not responding to treatment.

The adoption of asthma guidelines by clinicians and patients has been slow. Large numbers of asthmatics still have no written plan of action, do not own PF meters, and have a poor understanding of many aspects of their disease.11 12 13 The authors observed poor asthma knowledge and undertreatment of many patients presenting with a chief complaint of asthma to a large university emergency department (ED). It appeared that the management of many of these ED patients was not in compliance with the Consensus guidelines.

To date, little work has been undertaken in the United States to determine compliance with asthma management guidelines. Moreover, the compliance of patients presenting to the ED is unknown. The aim of this study is to establish whether the asthma management of ED patients is in compliance with each of the six parts of the Consensus guidelines.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
The study was a descriptive survey undertaken in the ED of the University of Pittsburgh Medical Center (Presbyterian), Pittsburgh, PA. The study period was 12 months duration (from July 1, 1997, until June 30, 1998, inclusive). A convenience sample of eligible subjects was enrolled. Inclusion criteria were a presentation with asthma-related symptoms requiring treatment, a history of asthma diagnosis and treatment, and age of 18 to 54 years (inclusive). Patients who refused or were too ill to participate in the survey were not enrolled. Sampling usually occurred between 7:00 AM and 11:00 PM daily, and potential subjects were identified by the triage nurse and ED care providers. Most subjects were enrolled by two research assistants who had been trained and dedicated to the study. At a suitable time during each subject’s ED course, the assistants administered a study questionnaire and evaluated inhaler technique. The study was approved by the Institutional Review Board of the University of Pittsburgh, and signed consent was obtained from each subject.

The study questionnaire allowed for classification of subjects as mild, moderate, or severe asthmatics, in accordance with the Consensus guidelines.2 The subjects were classified according to their clinical features and medication needs and were placed into the highest severity class in which they had features. The questionnaire included subject demographics; relevant medical history; and information on asthma knowledge, management, medication, and use of PF meters. One questionnaire item asked the subjects to explain the concept of PF. Their understanding was recorded as "good" if they described the fastest, most forceful blowing of air from the lungs; "poor" if they showed little understanding for the need of speed or force; and "no idea" if they had never heard of PF. Each subject’s inhaler technique was critically evaluated by the research assistant using a blank (placebo) asthma inhaler. A list of 11 common mistakes in inhaler technique14 was used, and the mistakes made by each subject were recorded on a standardized data collection form.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Subject Demographics
Female subjects predominated, accounting for 63 of the 85 enrollees (74.1%). There were 8 mild (9.4%), 19 moderate (22.4%), and 58 severe asthmatics (68.2%) enrolled. Forty-four subjects were white (51.8%), 40 were African American (47.1%), and 1 was Asian American (1.2%). Sixty-five subjects (76.5%) had suffered from asthma for at least 6 years. Four mild (50%), 16 moderate (84.2%), and 52 severe asthmatics (89.7%) had health insurance. Sixteen subjects (18.8%) required admission to the hospital for asthma treatment.

Assessment of Compliance With the Consensus Guidelines
Part 1. Asthma Knowledge: Table 1 describes the responses given when the subjects were asked to identify all of the things that happen to the lungs during an asthma attack. Bronchospasm was the most common response, although fewer than half of the subjects (42.4%) knew that this occurred. About one third of the subjects (37.7%) knew that airway swelling occurred. Fourteen subjects (16.5%), including 6 severe asthmatics, were unable to identify any pathologic process. Sixty subjects (70.1%) were able to identify one process only. Only four subjects (4.7%), all severe asthmatics, were able to identify that bronchospasm, airway lining swelling, and increased secretions all occurred during an attack.


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  		Table 1.. Patient Responses to the Question, "What Happens to the Lungs During an Asthma Attack?"*

 
Table 2 describes asthma drugs taken by the subjects. For each drug, the subjects were asked if it was a "reliever" or "preventer" of asthma symptoms, or both. The mild asthmatics used short-acting bronchodilators only, and all correctly stated that these were "relievers." However, 10 moderate (52.6%) and 16 severe asthmatics (29.1%) who were taking short-acting bronchodilators did not identify them as relievers only. Similar responses were seen with the long-acting inhaled bronchodilators and theophylline preparations. Of those taking inhaled steroids, two moderate (40%) and nine severe asthmatics (25.7%) did not identify these drugs as "preventers" of symptoms only. Other drugs were taken by a small number of subjects. Seven asthmatics (8.2%), one moderate and six severe, used ipratropium. Two subjects (2.4%), one moderate and one severe asthmatic, used cromolyn sodium. Eight subjects (9.4%), one moderate and seven severe asthmatics, used zafirlukast (a leukotriene inhibitor).


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  		Table 2.. Asthma Drugs Taken by the Subjects and Their Knowledge of Drug Action*

 
Table 3 describes the mistakes in inhaler technique made by the subjects. No mild (0%), four moderate (21.1%), and eight severe asthmatics (14.0%) had perfect technique. Forty-eight subjects (57.1%) made at least three mistakes. The most common mistakes were not waiting 1 min between puffs, not tilting the head back, not holding the breath for 10 s, and not inhaling the spray deeply. The mean number of mistakes made by the subjects was similar for the three groups.


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  		Table 3.. Mistakes Made by the Subjects When Demonstrating Their Inhaler Technique*

 
Table 4 describes those persons who taught the subjects the most about their asthma. Multiple responses were allowed. For each group, the subjects’ primary care physician/general practitioner (PCP/GP) was the most common response. Many subjects stated that their family and friends were an important source of asthma education, and 18 subjects (21.2%) stated that family and friends were the only source. One mild (12.5%), two moderate (10.5%), and one severe asthmatic (1.7%) reported receiving no education about their disease.


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  		Table 4.. Person Who Taught the Subjects the Most About Their Asthma*

 
Part 2. PF: The subjects were asked to explain their understanding of PF, and their explanations were graded by the research assistants. The results are described in Table 5 . Nearly half of the subjects (47.1%) had a poor understanding, and about one fourth of the subjects (25.9%) had no understanding of the concept, including 11 severe asthmatics (19.0%). No mild (0%), 7 moderate (36.8%), and 37 severe asthmatics (63.8%) owned a PF meter. Of all 85 enrollees, no mild (0%), 4 moderate (21.1%), and 28 severe asthmatics (48.3%) knew their best PF. No mild (0%), 2 moderate (10.5%), and 16 severe asthmatics (27.6%%) had measured their PF during the current exacerbation. Furthermore, no mild (0%), 1 moderate (5.3%), and 11 severe asthmatics (19.0%) measured their PF several times a week or more. Only eight subjects (9.4%), all severe asthmatics, measured their PF twice daily.


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  		Table 5.. Subject Understanding of PF*

 
Part 3. Asthma Triggers: The subjects were asked to identify some factors that may trigger asthma. Multiple responses were allowed. The results are described in Table 6 . Allergies was the most common response, followed by exercise and respiratory infections. Few subjects identified some foods, food additives, or drugs as asthma triggers. Seventy subjects (82.4%) identified three or more asthma triggers. Forty-one subjects (48.2%), including 16 smokers, identified cigarette smoke and fumes as asthma triggers. Overall, 5 mild (62.5%), 9 moderate (47.4%), and 20 severe asthmatics (34.5%) smoked.


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  		Table 6.. Factors Identified by the Subjects That May Trigger Asthma*

 
Part 4. Drug Regimens: The drug regimens of each subject were carefully reviewed. No mild (0%), 14 moderate (73.7%), and 39 severe asthmatics (67.2%) used drug regimens that were inadequate when compared to the Consensus guidelines.2 The frequency that the subjects used their short-acting bronchodilator increased with the severity group. All of the mild asthmatics reported using these bronchodilators infrequently (only with occasional asthma attacks). Three moderate (15.8%) and 11 severe asthmatics (19.0%) used these bronchodilators on most days. Nine moderate (47.4%) and 36 severe asthmatics (62.1%) used these bronchodilators daily. For unknown reasons, three severe asthmatics did not use a short-acting bronchodilator.

The subjects were asked to describe the steps they take, in sequence, in the event of a worsening asthma exacerbation. Seventy-six subjects (89.4%) used a bronchodilator and 6 subjects (7.1%) used an inhaled steroid as the first step. One subject began theophylline, one called the primary care physician, and one went directly to the ED. During an exacerbation, no mild (0%), two moderate (10.5%), and seven severe asthmatics (12.1%) commenced or increased an inhaled steroid. Seven subjects, all severe asthmatics, commenced or increased the dose of an oral steroid on their own. No mild (0%), 7 moderate (36.8%), and 30 severe asthmatics (51.7%) stated that they would call or see their doctor before going to the ED.

Part 5. Action Plans: No mild (0%), 1 moderate (5.3%), and 10 severe asthmatics (17.2%) reported having their own written plan of action to follow if their symptoms of asthma worsened. Of these, six plans had been provided by PCP/GPs, two by an asthma specialist, one by the subject’s parents, and one by an ED physician. One subject reported having made up his own plan.

Part 6. Follow-up Plans: Forty-nine subjects (57.7%) received routine asthma care from their PCP/GP. Nineteen subjects (22.4%), including 16 severe asthmatics, were managed by an asthma clinic or specialist. Three severe asthmatics (5.2%) were managed by an allied health worker, and one severe asthmatic (1.7%) by his mother. Twelve subjects (14.1%), including 2 severe asthmatics, stated that no one managed their asthma. Routine asthma care provision varied with insurance status. Of the 13 uninsured subjects, 5 subjects (38.5%) were cared for by no one, 4 subjects (30.8%) by a PCP/GP, 2 subjects (15.4%) by an asthma specialist or clinic, 1 subject (7.7%) by an allied health worker, and 1 subject (7.7%) by an ED. Of the 72 insured subjects, 7 subjects (9.7%) were cared for by no one, 45 subjects (62.5%) by a PCP/GP, 17 subjects (23.6%) by an asthma specialist or clinic, 2 subjects (2.8%) by an allied health worker, and 1 subject (1.4%) by his mother.

The subjects were asked how often they saw a doctor for regular reviews of asthma. Eight mild (100%), 15 moderate (79.0%), and 30 severe asthmatics (51.7%) were reviewed once a year or less. Only eight severe asthmatics (13.8%) were reviewed monthly. The subjects were asked how many times they had been to an ED with an asthma attack in the last 12 months, excluding the present visit. Two mild (25.0%), 9 moderate (47.4%), and 36 severe asthmatics (62.1%) had presented on two or more occasions. Twenty-two severe asthmatics (37.9%) presented on three or more occasions.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This study demonstrates that many patients presenting to the ED with asthma lacked a basic knowledge of the disease and its treatment. This is evidenced by the number of subjects who were unable to describe basic asthma pathophysiology and the large number who did not know the action of their drugs. The finding that inhaler technique was generally suboptimal supports the work of others.15 Education in the proper use of inhalers is important to the overall care of asthma patients,13 15 16 and it is the responsibility of all health-care providers to educate their asthma patients. While this study shows that most subjects were educated by their PCP/GPs or asthma specialists, it is of concern that many received most of their information from family and friends. This study was not designed to determine the reasons for this finding, although the lack of health insurance or a regular PCP/GP may be explanations. This finding needs further investigation. The ED may offer an important opportunity for the assessment and reinforcement of inhaler technique.17

Our study patients demonstrated a poor understanding of the concept of PF, and only 52% owned a PF meter, well below the 100% rate of ownership recommended by the Consensus guidelines.2 Furthermore, < 10% used a PF meter daily, as recommended. These factors are likely to significantly limit the usefulness of PF measurement as a tool in asthma management among this population. Other investigators also have shown that compliance with daily PF measurements is poor in chronic stable asthmatics.18 19 Furthermore, asthma patients who do not use PF meters are likely to underestimate disease severity and are at increased risk of morbidity and mortality.20 Simply prescribing PF meters without a system of self-management and regular review will be unlikely to improve patient care.13 21 In contrast, PF-based action plans have been shown to be effective in protecting patients against severe exacerbations of asthma and need to be encouraged.22 Our findings suggest that many ED patients with asthma either do not have an effective PF-based action plan or do not follow one.

Overall, most subjects had a reasonable knowledge of asthma triggers. The subjects may have obtained this knowledge through a combination of asthma education and their own personal exposures to these triggers. Therefore, it is difficult to attribute their knowledge to good asthma education only. We found that severe asthmatics could identify more allergens than mild asthmatics. This was not surprising, because the severe asthmatics are likely to have more brittle disease, and they are more susceptible to and aware of environmental triggers.

Interestingly, 40% of the subjects smoked, even though smoking is an asthma trigger. This proportion was higher than that of the general population, in which the proportion is estimated at 22 to 25%.23 The high proportion in this study may reflect poor asthma education, a disregard for their own health, a lack of volition or success in attempts to give up cigarettes, or selection bias with asthmatics who smoke being more likely to require ED treatment. Not only does this finding indicate a problem to be confronted by health-care providers, it raises the question of whether attempts are being made by the subjects to avoid other triggers.

We found that the large majority of subjects used drug regimens that were not in compliance with the Consensus guidelines. It is likely that many subjects are, in fact, undertreated. This is consistent with the findings of other studies11 12 13 and is supported by the present finding that over half of all subjects required their short-acting bronchodilator daily. Alternatively, it is possible that the Consensus guidelines classifies too many patients into higher-severity asthma groups, effectively causing some patients to appear undertreated. Furthermore, since the guidelines were published in 1992, new asthma drugs have been developed (eg, leukotriene inhibitors) that may have rendered the drug regimens of the guideline out-of-date.1 Hence, a regimen inclusive of these newer drugs may, in fact, be adequate for subject management but "noncompliant" with the guidelines. Also, this study may have deemed some drug regimens as inadequate because some subjects underreported the drugs they use.

The lack of use of some specific drugs is troubling. Short-acting bronchodilators are recommended for all asthma patients,2 8 and no explanation can be given for the three severe asthmatics who did not use these drugs. Also, the use of inhaled anti-inflammatory drugs (steroids and cromolyn sodium) was much lower than recommended.2 8 Only 52% of the moderate and severe asthmatics used these drugs, although they are usually required for all asthmatics in these groups.2 These findings are consistent with the well-documented undertreatment of asthma11 12 19 24 25 and possibly contributed to the high rate of short-acting bronchodilator use in this study.

Not surprisingly, most patients reported using a short-acting bronchodilator as the first step in managing an exacerbation. However, few subjects commenced or increased an inhaled or oral steroid. These findings are consistent with those of other investigators who have reported that regular preventative inhaled steroids are underutilized13 19 24 25 26 and that oral steroids are rarely commenced in response to near-fatal asthma attacks.24 The present finding that two subjects required the advice of their doctor or the ED before initiating any treatment and that fewer than half of all subjects called or visited their doctors before going to the ED reflects poor patient management strategies during an exacerbation. These inadequate strategies suggest that many patients lack either the knowledge, confidence, or drugs to adequately manage an exacerbation.

Only 13% of patients had a plan of action in this study. In contrast, Beilby et al27 reported that 46% of asthmatics from an Australian community had a plan and Hartert et al13 reported that 28% of patients admitted with asthma to a large United States hospital had a plan. The enrollment of subjects from differing asthma populations may account for the observed variation in rates. Even if more patients owned plans of action, they may not implement them, even in the event of a potentially life-threatening attack.28 29 This may limit the impact of plans of action on care.

It is disconcerting to find that many subjects did not identify a primary care provider for asthma care and that the frequency of routine care visits was low. Although the Consensus guidelines recommend reviews every 1 to 6 months for all asthmatics, 62% of subjects waited >= 12 months between reviews. Additionally, the proportion of severe asthmatics (28%) who were managed by an asthma specialist was well short of the 100% recommended by the guidelines. The reasons why many did not seek regular review or see a specialist, even though most had health insurance, is not known. The results also reveal that a larger proportion of uninsured subjects had no health-care provider and that a smaller proportion attended a PCP/GP or asthma specialist/clinic. This is an important finding, and larger studies investigating the association between insurance status and asthma management are recommended. The lack of appropriate medical management of the subjects in this study may explain their poor asthma knowledge, inadequate drug regimens, frequency of symptoms, bronchodilator requirements, and frequent ED presentations.

This study has several limitations. It was undertaken at only one ED using convenience sampling and enrolled a relatively small number of subjects. Also, the population of ED patients may not be representative of all asthma patients. There was the potential for subject recall bias. Furthermore, observer interpretation of subject responses to the pathophysiology and understanding of PF questions, and the assessment of inhaler technique may have been inconsistent.30 The reasons for the poor guideline compliance observed in this study are not obvious and are likely to be multifactorial. This study was not designed to determine these reasons.

This study demonstrates that most patients presenting to the ED were not being managed in compliance with the Consensus guidelines. It highlights significant deficiencies in subject knowledge and monitoring, drug regimens, action during exacerbations, and rates of plan of action ownership. Studies conducted in other hospital EDs and primary care settings are required to determine if poor guideline compliance is widespread and to elucidate barriers to more appropriate patient management.


   Footnotes
 
Abbreviations: ED = emergency department; PCP/GP = primary care physician/general practitioner; PF = peak expiratory flow

Received for publication April 22, 1999. Accepted for publication July 15, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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